COURSE IN THE

WARD
COURSE IN THE
WARD

2
 Day 1
Subjective Objective Assessment Plan
Body Malaise Pallor Anemia of Chronic Dxtics: Repeat CBC with PC
Temperature: 38.2 Disease secondary to after 2 days
BP 100/60 rectal mass probably
HR 72 malignant, to consider Continue Cefepime
RR 20 occult LGIB
IVFTF: PNSS 1L x 60cc/hr
Rectal mass (Whole Bacteremia secondary to
abdominal CT Scan) infected PTBD catheter
secondary to hydropic
gallbladder

3
 Day 1

Subjective Objective Assessment Plan

6. Digoxin 0.25 mg/tab ½ tab OD
7. Aspirin 80mg/tab OD
8. Clopidogrel 75mg/tab 1 tab
OD
9. Mosegor 1 tab OD

Transfuse 1 unit PRBC properly

typed and crossmatched x 6
hours

Pre-BT: Hydrocortisone 100 mg

IV

Repeat CBC with PC 6 hours

post BT

IDS:
1. Cefepime 2gm IV q 8 hours
2. Paracetamol 300 mg IV now
Dxtics: For PTBD Tube CS/GS

4
 Day 2

Subjective Objective Assessment Plan

6. Digoxin 0.25 mg/tab ½ tab OD
7. Aspirin 80mg/tab OD
8. Clopidogrel 75mg/tab 1 tab
OD
9. Mosegor 1 tab OD

Transfuse 1 unit PRBC properly

typed and crossmatched x 6
hours

Pre-BT: Hydrocortisone 100 mg

IV

Repeat CBC with PC 6 hours

post BT

IDS:
1. Cefepime 2gm IV q 8 hours
2. Paracetamol 300 mg IV now
Dxtics: For PTBD Tube CS/GS

5
 Day 3

Subjective Objective Assessment Plan

Unable to sleep (+) edema on both Anemia of Chronic GI: Once CP cleared, for
upper and lower Disease secondary to proctosigmoidoscopy and biopsy
extremities rectal mass probably tomorrow AM, with intraop
malignant, to consider monitoring Give 1 Dulcolax
T: 39 deg C occult LGIB suppository tonight. Resume
insulin glargine 18 “u” SQ OD
Bacteremia secondary to
infected PTBD catheter Cardio: Patient is stratified as
secondary to hydropic intermediate to high risk for
gallbladder developing perioperative
complications. NPO post
midnight.

IVFTF: PNSS 1L x 60 cc/hour

Dxtics: For repeat procalcitonin

6
 Day 4

Subjective Objective Assessment Plan

T: 39 deg C Anemia of Chronic Intraop: Proctosigmoidoscopy
Disease secondary to and bopsy
Hematochezia rectal mass probably Nicardipine 1mg SIVP
malignant, to consider
Intraop: occult LGIB GI: Repeat CBC with PC once at
BP 180-200/70-80 room.
mmHg Bacteremia secondary to Send specimen for histopath.
infected PTBD catheter
secondary to hydropic Surgery: Plan to do laparoscopic
gallbladder cholecystectomy and diverting
loop ileostomy

GI: Start Bactrim Forte

(sulfamethoxazole and
trimethoprim) 1 tab BID
Paracetamol 300 mg IV every 4
hours for fever

IVFTF: PNSS 1L x 60cc/hr

7
 Day 4

Subjective Objective Assessment Plan

Blood CS: negative Anemia of Chronic Intraop: Proctosigmoidoscopy
PTBD CS: Status Disease secondary to and bopsy
epidermidis rectal mass probably Nicardipine 1mg SIVP
Sensitive to SXT malignant, to consider
occult LGIB GI: Repeat CBC with PC once at
Colonoscopy: with room.
areas of necrosis Bacteremia secondary to Send specimen for histopath.
and exudates on infected PTBD catheter
anal verge secondary to hydropic Surgery: Plan to do laparoscopic
gallbladder cholecystectomy and diverting
Procalcitonin: 4.66 loop ileostomy

GI: Start Bactrim Forte

(sulfamethoxazole and
trimethoprim) 1 tab BID
Paracetamol 300 mg IV every 4
hours for fever
Shift Cefepime to Tigecycline
100 mg IV now, then 50 mg q 12
hours

IVFTF: PNSS 1L x 60cc/hr

8
 Day 4

Subjective Objective Assessment Plan

No fever recurrence Bacteremia secondary to Continue Tigecycline.
infected PTBD catheter
secondary to hydropic For cardio clearance:
gallbladder Stratified as Intermediate to High
Risk
For intraop monitoring

Surgery:
For laparoscopic
cholecystectomy and diverting
loop ileostomy on Sept. 6

GI:
Prepare 4 units platelet
concentrate, 2 units PRBC for
possible perioperative use.

Transfuse 1 unit PRBC properly

type and crossmatched x 6
hours. No preBT meds

NPO post 10pm on Sept. 5

9
 Day 5

Subjective Objective Assessment Plan

No fever recurrence Bacteremia secondary to Cardio: For 12L ECG post op,
infected PTBD catheter Crea, K
secondary to hydropic
gallbladder GI: Repeat CBC with PC post BT

ID: Continue Tigecycline

Repeat Blood CS 2 sites,
ALT/AST

10
 Day 5

Subjective Objective Assessment Plan

No fever recurrence Bacteremia secondary to IVFTF: D5LRS 1L x 60 cc/hr
infected PTBD catheter
secondary to hydropic
gallbladder

11
 Day 6

Subjective Objective Assessment Plan

No fever recurrence Status post lap chole with IVFTF: D5LRS 1L x 60 cc/hr
diverting loop ileostomy
Mg: 0.50 Postop:
K: 2.49 Hypokalemia 1. Tramadol 50 mg SIVP q 8
hours x 3 hoses then shift to
Paracetamol 1 tab q 8 hours
2. Ketorolac 50 mg SIVP q 8
hours x 2 doses then
discontinue

IVFTF: PNSS 1L + 40 mEqs KCL

to run for 80 cc/hr

12
 Day 7

Subjective Objective Assessment Plan

No fever recurrence Bacteremia secondary to Shift Tigecycline to TMP-SMX 1
infected PTBD catheter tab BID
Wound CS: S. secondary to hydropic
epidermidis gallbladder Fast drip 50-100 cc now then
Sensitive: TMP-SMX regulate 80 cc/hr
Hold carvedilol and Entresto if
Cath tip CS: No BP 90/60
microorganisms Discontinue KCL tablet

BP 90/60 IVFTF: PNSS 1L x 50 cc/hr

13
 Day 8

Subjective Objective Assessment Plan

Dyspnea Intake: 2150mL Acute pulmonary Furosemide 40 mg IV stat
Chest pain Output: 850mL congestion probably Start Clexane 0.45 cc q 12
secondary to fluid Calcium Gluconate 1 vial now
O2 sat: 91% overload Nebulize with Duavent x 1 doses

HGT: 165 mg/dl T/C ACS Hold antihypertensive meds

Decrease IVF to KVO
iCa: 1.1 Insert IFC
Monitor ileostomy output q shift

Repeat CBC stat, Na, K, Crea,

PT, PTT, cardiac panel, ABG,
CKMB, Trop I
CXR PAV

Transfer to CCU

14
 Day 8

Subjective Objective Assessment Plan

Dyspnea, chest ECG: ST evelation STEMI Start NTG drip (10 mg)
heaviness, cold V2 to V4 Morphine 2 mg SIVP PRN for
clammy skin chest pain
BP 120/80 Furosemide 40 mg IV
HR 108
RR 22 Suggest coronary angiogram

Basal fine crackles, ID: Start doxycycline 100 mg/tab

R lung 1 tab BID
Hold cotrimoxazole
O2 sat: 98-99%

PCT: 1.94
WBC: 26.17, Neutro
62

Wound CS: CONS,

sensitive to SXT,
tetracycline

15
 Day 9

Subjective Objective Assessment Plan

No chest pain BP 120/50 STEMI Continue medications
Occasional HR 96
shortness of RR 22 Cardio: Repeat Na, K, Crea,
breath O2 sat: 96%
No cough
No febrile Occasional crackles
episode on R lung

CXR: no pneumonia

16
 Day 10

Subjective Objective Assessment Plan

Palpitations BP 150/40 STEMI ECG now
Shortness of HR 130-150 For Trop I
breath
K: 4.5 Give Amiodarone 150 mg SIVP
Crea: 143 now
Na: 132 Hold Digoxin
Start Isoket drip

Hematochezia Repeat CBC with PC, iCa,, Mg,

Crea tomorrow
Hold Clexane

17
 Day 11

Subjective Objective Assessment Plan

Dyspnea Bibasal rales STEMI Continue Doxycycline
Give Calcium Gluconate 1 amp
BP 130/80 SIVP stat
HR 127
RR: 20 Transfuse 1 unit of PRBC
property typed and crossmatched
iCa: 1.1 for 5 to 6 hours
Mg: 1.24
Crea 103 PreBT: Diphenhydramine 50 mg
K: 4.51
Na: 132
WBC: 14,800 Neutro
78

18
 Day 12

Subjective Objective Assessment Plan

No dyspnea BP 90/40 STEMI Consume amiodarone then D/C
No chest pain HR 100 Decrease clexane q 24 hours
No palpitations RR 20 Start metoprolol 50 mg/tab ½ tab
No cough BID
No phlebitis
IDS: Continue antibiotics for 2
more days

19
 Day 13

Subjective Objective Assessment Plan

No dyspnea BP 90/40 STEMI D/C Furosemide
No chest pain HR 100 Start Jardiance 25mg/tab 1 tab
No palpitations RR 20 OD
No cough Isordil 5 mg tab SL PRN for chest
No phlebitis pain

Repeat CBC with PC, K, Crea

Remove IFC

20
 Day 14 (CCU)

Subjective Objective Assessment Plan

No dyspnea K: 3.46 IVFTF: PNSS 1L x 10 cc/hr
No chest pain Crea: 85.6
No palpitations CBG: 161 Incorporate 40 mEqs KCL to
No cough WBC: 13.52 prevent IVF
No phlebitis Shift Ensure to Glucerna
BP: 120/80 Increase metoprolol to 50 mg/tab
HR: 70 BID
RR: 20
O2 sat: 98% May transfer to regular room

21
 Day 14 (ROC)

Subjective Objective Assessment Plan

Dyspnea ECG: LBBB, CAD Furosemide 40 mg IV now
Chest pain discordant ST Isordil 50 mg tab SL now
depression on lateral Start nitrate drip
leads Start enoxaparin 0.4 cc SQ OD

(+) wheezes 12L ECG

HGT: 246 Transfer back to CCU

For 2D Echo tomorrow

22
 Day 15

Subjective Objective Assessment Plan

No chest pain Occasional wheezes CAD Hold Isoket drip
BP 95/40 Resume ISMN 30 mg OD
HR 76 Morphine 2 mg IV PRN for chest
RR 24 pain

23
 Day 16

Subjective Objective Assessment Plan

No chest pain BP 120/80 CAD Stat CBC with PC, Crea, Na, K
HR 73 ABG
RR 20
Start NaHCO3 tab now then TID
ABG: Metabolic
acidosis IDS: Procalcitonin

Occasional wheezes

24
 Day 17

Subjective Objective Assessment Plan

Chest tightness Procalcitonin 2.57 Bacteremia? Start Ceftazidime 2 grams IV q 8
K 4.83 hours
Crea 123
Na 136

BP 100/60
HR 69
RR 21

Bibasal crackles

25
 Day 18

Subjective Objective Assessment Plan

Chest tightness BP 105/50 To consider infective For blood C/S 3 sites 1 hour
HR 70 endocarditis apart
RR 20
Shift Ceftazidime to Meropenem
CBG 147 mg/dl 1 gram q 8 hours

Occasional crackles Start gentamicin 100 mg IV q 8

hours

Dxtics: ESR, Crea

Cardio:
D/C Clexane
Shift Glucerna to Glucobest
Start Entresto 50 mg/tab ½ tab
BID

26
 Day 19

Subjective Objective Assessment Plan

Chest tightness BP 105/50 To consider infective IDS: Continue meropenem and
HR 70 endocarditis gentamycin
RR 20
Cardio: Decrease Furosemide to
ESR: 22 20 mg/tab 1 tab OD
Crea: 1.447 Discontinue anti-embolic therapy
EGFR: 50.3

Difficulty of ECG: Atrial Give amiodarone 150 mg IV now

Breathing Fibrillation For CBC with PC, Na, Ica, Crea,
K

Give Calcium Gluconate 1- mg

SIVP

27
 Day 20

Subjective Objective Assessment Plan

Episodes of BP 80/40 To consider infective IDS: Continue meropenem
hypotension HR 70 endocarditis Revise gentamicin to 60 mg q 8
RR 20 hours
WBC: 15
Na: 134 Repeat Crea on Sept 22
K 4.13
iCa 1.11 Cardio: Start Atorvastatin 10
Mg 0.63 mg/tab BID

Blood C/S 3 sites:

negative

28
 Day 21

Subjective Objective Assessment Plan

No chest pain BP 100/40 To consider infective Cardio: Furosemide 20mg/tab 1
No dyspnea HR 72 endocarditis tab OD
RR 20 Aldactone 25 mg/tab ½ tab OD

IVFTF: PNSS 1L x 10 cc/hr

29
 Day 22

Subjective Objective Assessment Plan

No chest pain BP 100840 To consider infective Shift ASA and Clopidogrel to
No dyspnea HR 73 endocarditis Norplat-S 1 tab OD
RR 20 D/C Morphine

O2 sat: 100%

Crea: 98.1
HGT: 134

30
 Day 23

Subjective Objective Assessment Plan

No chest pain BP 100/40 To consider infective Start Losartan 50 mg/tab ½ tab
No dyspnea HR 73 endocarditis OD
RR 20 Increase Furosemide to 20
mg/tab BID
O2 sat: 100% Start Pantoprazole 40 mg IV

Crea: 98.1
HGT: 134

31
 Day 23

Subjective Objective Assessment Plan

Leg pain BP 85/40 To consider infective Hold Losartan
HR 75 endocarditis Increase IVF to 20 cc/hr
RR 20 For CBC, Crea, Na, K, Mg

O2 sat: 100%

CBG: 147

Occasional crackles
bibasal

32
33