Subjective data

50
CC :
HPI: 1 wk PTA . ascites
1 d PTA

PMH:
cirrhosis
MH : Lasix 40 mg 1*1 or Spironolactone 20 mg 1*1
Propanolol 10 mg 2*2
FH: SH: 1

ALL : NKDA

Objective data
PE;

GA : looked illness , BW 45 kg, Wt 165 cm

V/S : BT 37, PR 78/min, RR 20/min, BP 110/70 mmHg
HEENT : marked jaundice
Heart : normal
Lung : normal
Abd : distend, ascites (+)
Ext : normal
Lab : Na 121 mg/dl, K 5.2 mg/dl
Clinical Chemistry
Test

norm
al

12.
05

24
25

21.3 8.19
3

Cr
(mg/dL)

0.71.2

0.9

Na
(mEq/L)

136145

127 121

123

K
(mEq/L)

3.55.1

4.1

4.8

5.2

25
26
27

18.2 7.48 8.05

6

28
.
11.2
9

29
.
14.0
5

124

125

131

126

126

4.6

4.6

5.1

CO2
(mEq/L)

22-29 19

21

Cl
(mEq/L)

98107

83

Anion
Gap

10-20 17.
8

94

89

86

94

22.6

Urinalysis
Test

Normal

Turbid

. 13.45

clear

color

Test

Normal

. 13.45

Urine ketone

1+

Blood

neg

Sp gr

1.020

Bile

neg

pH

Urobil

Trace

Alb

1+

Epi

0-1

Sugar

neg

leucocyte

neg

WBC

0-1

nitrite

neg

RBC

Bac

Few

Cast

Hyaline cast 0-1

Progession

order for one day

26 .. 58

lasix 40mg IV q 6hr

(hold BP < 90/60)

2+
I/O 1690/1300
hyponatremia
27 .. 58

NSS 1000ml 60 cc/hr

3% NaCl 500 ml 20 cc/h
- notify Lab
- 3 % NaCl 500 ml iv 20

order for
continuous

folic 1x2 pc
ferrous
fumarate 1x3
pc
2 /
Aldactone 1x3

28/9/58
Na = 125

cc/hr
Repeat Electrolyte

pc
Lasix 20 mg 1x1
pc

Home medication
Aldactone 25 mg 1x2 pc # 20 tab
1x1 pc # 10 tab
Folic 5 mg
1x1 pc # 10 tab
fumarate
1x3 pc # 30 tab
Propanolol 10 mg 2x2 pc
# 40 tab
complex 1x3 pc # 30 tab
Kalimate 30 g OD 3 days

Lasix 40 mg
Ferrous
Vitamin B

Vital sign
Test Date

24/9/
58

25/9/5 26/9/58 27/9/58

8

28/9/5
8

29/9/
58

PR

78

80

75

74

BT

36.5

36.7

36.6

36.6

RR

20

20

20

20

20

20

BP

120/6 114/6
0
7

107/63

106/63

105/62 110/7
0

Wt

45

tot intake

1690

1655

1930

1400

urine out

1300

1500

1700

1700

stool

urine

0 1

1
2

5
Med reconciliation
1. Propanolol (10) 2x2 pc #10
(25) 1x3 pc #60

2
3

2
pp

5. Spironolactone

2. Furosemide (40) X1 pc 1X2 pc #10

6.
Omeprazole (20) 1x2 ac #40
3. B complex 1x3 pc #60
7. Lactulose SYR.
100 ml 1 hs #1
4. Simethicone (80) 1x3 pc #20
8. Unison 100 cc
#1
Impression : Liver cirrhosis

Assessment

50

1

1 .
ascites
distend, ascites (+)
Cirrhosis

Ascites
Management of Adult Patients with Ascites Due to Cirrhosis:
Update 2012 2000 mg/day
serum sodium < 120 mEq/L
diuretic spironolactone Furosemide

spironolactone 25 mg tid Furosemide 40 mg bid
100 : 106
100 : 40 Potassium Spironolactone
200 mg Furosemide 80 mg

Plan
Med :
Spironolactone 200 mg
Furosemide 80 mg
Goal : Ascites
Efficacy monitoring :

CBC, LFT, Electrolyte, BUN,

SCr,

 Abdominal X-ray
Sise effect monitoring :
Drugs
Spironolactone

Furosemide

Side effects
Headache,
weakness, nausea,
rash&dizziness
gynecomastia
Electrolyte
disturbances,
dehydration&hypov
olemia, increase
blood
creatinine&triglycer
ide, Hypotension

Monitoring
Serum K,HR

CBC, I/O, Cr, BP

Patient education:
-
-

-
-

Vilstrup H et al (2014) Hepatic encephalopathy in chronic liver

disease: 2014 practice guideline by the
American association for the study of liver diseases and the
european association for the study of the liver. Hepatology
60:715735. doi:10.1002/hep.27210