MEDICAL MANAGEMENT

IDEAL

Chemotherapy:

 Folfirinox (folinic acid [ leucovorin], 5- fluorouracil, irinotecan, oxaliplatin) – Neoadjuvant and adjucant therapy, and first- line therapy in metastatic disease
 Albumin- bound paclitaxel plus gemcitabine
 Gemcitabine monotherapy – often in a palliative setting in frail patients
 Gemcitabine plus capecitabine (GemCap) – in the adjuvant setting, for patients who cannot tolerate FOLFIRINOX
 Eriotinib plus gemcitabine – third-line therapy
 OFF (Oxaliplatin, folinic acid, 5-FU) – Second-or third line therapy
 CapeOx (capecitabine, oxaliplatin)- second or third line therapy
 Larotrectinib or entrectinib – second line therapy in patients with tumors harboringNTRK fusions
 Pembrolizumab (with or without ipilimumab) – for deficient mismatch repair tumors or in patients with Lynch syndrome
 Gemcitabine + cisplatin – only known BRCA1/2 or PALB2 mutations)

Maintenance therapy:

 Olaparib – oral maintenance treatment for adults with deleterious or suspected deleterious germline BRCA-mutated metastatic pancreatic adenocarcinoma whose
disease has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen.

Supportive care:

 Used in conjunction with active anticancer therapy or as a primary modality in patients approaching end of life
 Pain relief – Non-opioid and opioid analgesics, celiac plexus lysis performed endoscopically or under CT guidance.
 Dietary and nutritional support, management or pancreatic insufficiency
ACTUAL 03/04/2023
 Place on clear liquid diet
02/28/2023
 Start Suplenex 1 bottle to run for 12 hours
 Admission of patient
Medications:
 Secure Consent
 Metronidazole 500mg IV q 8H
 Start Intravenous Fluid with PLR 1L @ 20gtts for 8 hours
 Insert Foley Catheter
03/06/2023
 Low fat low salt diet
 Low fat low salt diet
Prescribed Medications:
 Add 1 banana per meal
 Omeprazole 400mg IV q 4H  Continue medical management
 Hyoscine N-Butylbromide (HnBB) 10mg IVTT q 8H Medication:
 Ceftriaxone 2g IVTT q 24H  Facilitate repeat Potassium (K)
Laboratory: Laboratory:
 Alkaline Phosphatase  Facilitate Computed Tomography (CT) Scan
 Cancer Antigen 19-9 (CA 19-9)
 C/S Urine Test 03/07/2023
 Triple-contrast Computed Tomography (CT) Scan  Follow-up official Computed Tomography (CT) Scan
result
03/03/2023 Medications:
 Low salt low fat diet  Continue Medications
 For chest X-ray lateral decubitus view & PAL view
 Remove Foley Bag Catheter 03/08/2023
 For 12 Lead Electrocardiogram (ECG)  Follow-up official Computed Tomography (CT) Scan
 For Urinalysis, Na, K, Mg, INR, HbA1C result
Medications:  IVTF PNSS iiL @ SR
 Continue Medications  Continue diet and keep monitored
Medications:
 Continue medications and management
03/09/2023
03/13/2023
 Low salt, Low fat diet
 Low fat diet
 Follow-up official Computed Tomography (CT) Scan
 Follow-up ERCP scheduling
result
 Secure consent for procedure
Medications:
 For ECG-12L
 Continue medications
Medications:
 Continue IV Fluid and medications
03/10/2023
Laboratory:
 Continue diet
 Repeat CBCP, Creatinine, Na, K, BUN
 Continue present management
Medications:
03/14/2023
 Continue medications
 Low fat diet
03/11/2023  Continue present management
Medications:
 Continue diet
 Continue medications
 Continue present management
Medications:
03/15/2023
 Continue medications
 Low fat diet
03/12/2023  IVTF PNSS iiL @ SR
 Low fat diet  Continue present management
Medications:
 For Endoscopic retrograde cholangiopancreatography
 Continue medications
(ERCP) scheduling
 Continue present management
Laboratory:
03/16/2023
 Repeat real-time reverse transcription polymerase  Low fat diet
chain reaction (rRT -PCR), bilirubin (TB/DB/IB), SGPT  For Endoscopic retrograde cholangiopancreatography
(serum glutamic-pyruvic transaminase) and SGOT (ERCP) tentative schedule tomorrow, friday (March
17, 2023)
(serum glutamic-oxaloacetic transaminase)
 Continue present management
Medications: Medications:
 Continue Medication
 Start Potassium Chloride (KCl) tabs 2 tabs q6H x 4
doses
 Start Potassium Chloride (KCl) drip: 10mEqs + 90cc
PNSS to run for 1-2 hours x 6 cycles
 NURSING MANAGEMENT

IDEAL

 Assessment of current nutritional status and increased metabolic requirements.

 Assessment of respiratory status
 Assessment of fluid and electrolyte status

ACTUAL

 Secure consent to care

 Monitored Vital signs every 4 hours
 Monitored Intake and Output every shift
 Hooked patient to cardiac monitor
 Performed physical examination and reviewed the history of illness
 Inserted indwelling Foley Catheter
 Performed bedside care to patient
 Monitored low fat low salt diet and added 1 banana per meal
 Regulated IVF 1L at 20 gtts and checked for patency
 Administered medications such as omeprazole, HnBB, ceftriaxone, metronidazole, and potassium chloride
 Monitored patient for side effects from medications taken
 Referred to IM gastro for evaluation and co-management
 Evaluated decrease of urine output and bowel movement
 Placed patient on bed rest in a fowler’s position for better chest expansion, improving breathing by facilitating oxygenation
 Started Potassium Chloride drip 10mEqs + 90cc PNSS to run for 1-2 hours
 Prepared pre-operation for Endoscopic retrograde cholangiopancreatography (ERCP)
 Assisted in change of dressing
 Removed Foley Bag Catheter
 Removed Indwelling Foley Catheter
 SURGICAL MANAGEMENT

A wide spectrum of benign and malignant diseases can produce a mass in the pancreas. It can be either solid tumor (e.g. ductal adenocarcinoma, chronic pancreatitis,
endocrine tumor) or a cystic lesion (e.g. cystic neoplasm, true cyst or pseudocyst). Whereas, Choledocholithiasis is the presence of at least one gallstone in the common bile
duct. The stone may be made up of bile pigments or calcium and cholesterol salts. The liver produces bile which aids in the digestion of fats. The surgical management that can
be put into action is:

 Endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic retrograde cholangiopancreatography, or ERCP, is a procedure to diagnose and treat problems in
the liver, gallbladder, bile ducts, and pancreas. It combines X-ray and the use of an endoscope—a long, flexible, lighted tube. The healthcare provider guides the scope
through mouth and throat, then down the esophagus, stomach, and the first part of the small intestine (duodenum). The healthcare provider can view the inside of these
organs and check for problems. Next, he or she will pass a tube through the scope and inject a dye. This highlights the organs on X-ray.

How to prepare for ERCP?

To prepare for ERCP, talk with your doctor, arrange for a ride home, and follow your doctor’s instructions.
1. Talk with your doctor

You should talk with your doctor about any allergies and medical conditions you have and all prescribed and over-the-counter medicines, vitamins, and supplements you
take, including:
 arthritis medicines
 aspirin or medicines that contain aspirin
 blood thinners
 blood pressure medicines
 diabetes medicines
 nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen
Your doctor may ask you to temporarily stop taking medicines that affect blood clotting or interact with sedatives. You typically receive sedatives during ERCP to help you
relax and stay comfortable.
2. Arrange for a ride home

For safety reasons, you can’t drive for 24 hours after ERCP, as the sedatives or anesthesia used during the procedure needs time to wear off. You will need to make plans
for getting a ride home after ERCP.
3. Don’t eat, drink, smoke, or chew gum

To see your upper GI tract clearly, you doctor will most likely ask you not to eat, drink, smoke, or chew gum during the 8 hours before ERCP.