III.

PATIENT PROFILE

Name: M.D.
Age: 44 y/o
Gender: Female
Nationality: Filipino
Civil Status: Married
Religion: Roman Catholic
Address: Quezon, City
Date and Time Admitted: July 6, 2007; 3:00 PM
How Admitted: Wheelchairborne
Attending physician: De Ocampo, Sherrie Isabel Querubin
Occupation: Police Officer
Hospital Plan: Individual
Source of Information: Patient

Chief Complaint: “Masakit ang tiyan ko dito sa kanan, sa bandang itaas”

A. History of Present Illness:

Three months prior to admission, the patient developed epigastric pain (pain scale:
9/10), localized, burning lasting for hours. The patient denied any history of melena,
hematochesia, constipation, diarrhea, belching, and regurgitation. The patient sought
consultation at Capitol Medical Center where she was given Prevacid for 3 days and was
diagnosed to have Acid Related Disease.

Due to the presented symptoms, the patient again sought consult at SLMC where she
underwent an ultrasound around her abdomen and it showed gallbladder stones. The patient
was advised Extracorporeal Shockwave Lithotripsy (ESWL) but she developed icteresia and
was advised surgery thus admission.

Patient’s Medical History: Cholelithiasis (August 1, 2005), (-) DM,

(-)HPN, (-)Asthma, (-) Heart Disease
Surgery: Cesarian delivery (CS) (1989)

OB- Gyne History:

Menarch: 13 y/o
Parity: Primi
Gravida: 1
TPAL: Term =1 Preterm = 0 Abortion = 0 Live birth = 1
Contraceptives: none
LMP: July 5, 2007

Family History:
GI disorder: Father, Mother
Heart Disease: Father, Mother

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B. PHYSICAL EXAMINATION
Date Taken: 07 / 09/ 07 (1:30 PM)

a. General Survey:
Apparent State of Health:
Signs of Distress: With mild restlessness
Skin Color: Slightly jaundiced
Height and Built: 163 cm; proportionate limb
Weight by appearance and measurement: 64 kg; fat
Posture, Motor Activity, and Gait: Good posture, normal motor activity,
normal gait
Dress, Grooming, and Personal Hygiene: Wears loose clothing, well groomed,
good personal hygiene
Odors of Body or Breath: No body odor, no halitosis
Facial Expression: With facial grimace
Speech: No speech defect, no hoarseness of voice

b. Vital Signs:
Blood Pressure: 130/90 mmHg
Respiration Rate: 22 breaths per minute
Pulse Rate: 94 beats per minute
Temperature: 36.5 °C
Pain Scale: 6/10

c. Mental Status
Appearance and Behavior:
Speech and Language:
Mood:
Thought and Perceptions:
Cognitive Functions:
Alert, conscious, with guarding behavior
Speaks with clarity, fluent in speaking tagalog/ english
With anxiety due to pain
Coherent, with organization of thoughts, no
hallucinations
Memory intact, oriented to time, place, and person

d. Regional Examination:

I. SKIN
I: Slightly jaundiced with absence of lesion.
P: Moist, warm and smooth to touch, has good skin mobility and turgor (goes
back quickly to normal when pinched).

II. NAILS
I: Transparent, smooth and convex with a 160˚ nail bed angle.
P: Normal capillary refill (2 seconds).

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III. HAIR
I: Thick and evenly distributed.
P: Fine and smooth to touch.

IV. HEAD AND FACE

I: Proportion to the gross body structure. Facial hair is evenly distributed.
P: No tender areas, masses, or deformities.

V. EYES
I: Eyebrows are symmetrical. The pupils and iris are also symmetrical. With
yellowish discoloration of sclera (icteresia). There is no obvious deformity
seen in the external eye structures.
for reaction to light: The patient has a normal pupillary reaction: constrict
with light and dilate in darkness.
for accommodation: The patient has a normal pupillary reaction: constrict
with a near object and dilate with a distant object.
for convergence: The patient has a normal convergence because she assumed
a cross-eyed appearance.
Visual acuity: The patient has a 20/20 vision.
Extraocular movement: The patient has a normal extraocular movement.

VI. EARS
I: The ears are symmetrical with a shape and size proportion to the face. There is
absence of cerumen or any discharge.
For hearing acuity: The numbers whispered to both ears with one ear
occluded at a time were heard clearly.

VII. NOSE
I: The patient’s nose is proportion to the face. The nasal bridge is aligned. The
mucous membranes are pinkish.
P: Patency of nares: No difficulty of breathing experienced.
There is no pain or discomfort felt upon palpating the frontal and maxillary
sinuses.

VIII. MOUTH AND PHARYNX

I: The lips are pinkish in color, quite dry but no ulcers present. The buccal
mucosa is pink, moist without any ulcers. Incomplete teeth alignment with
cavities and discoloration in some of the teeth. There is absence of swelling,
inflammation, or bleeding in the gums. The dorsum of the tongue is pinkish in
color. The tongue is symmetrical and mobile. The tonsils are symmetrical and
there is no swelling.

IX. NECK
I: The patient’s neck is mobile and proportion to the gross body structure. The
trachea is in its normal midline position. There is absence of neck vein
engorgement, masses, or scars.

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 Lymph nodes
P: The lymph nodes are normal in size and shape. No pain felt upon palpation.

Trachea and Thyroid

I: There is absence of any deviation.
P: The trachea and thyroid rises as the client swallows.

X. SPINE
I: The patient’s spine has a normal curvature.
P: There is absence of masses or lumps.

XI. CHEST AND LUNGS

I: The patient’s lungs have a normal shape.
P: Respiratory excursion: The patient has a symmetrical lung expansion.
Vocal and tactile fremitus: The vibration felt as the patient utters “99” is
more resonant on the upper part of the lungs.
Pe: The vibrating sound was heard louder on the upper part of the lungs. The
lower the area percussed, the softer the sound heard. The lungs have a
resonant sound.
A: The patient manifests a vesicular breath sound because the length of
inspiration is greater than that of the expiration. There is absence of abnormal
or adventitious breath sound.

XII. HEART
I: The Point of Maximum Impulse (PMI) was located on the 5th intercostal space
or the apical area.
P: The palpatory areas were properly identified (aortic, pulmonic, tricuspid,
mitral).
A: The auscultatory areas were properly identified. The S1 and S2, where the
“lub-dub” sound is best heard and pointed out.

XIII. ABDOMEN
I: The 4 quadrants and 9 regions were correctly identified, with presence of
surgical incision at right upper quadrant, no signs of inflammation over the
incision.
A: Gurgling sounds were heard over the abdomen, with normoactive bowel
sounds:22 per minute, no bruit.
Pe: The abdomen has a tympanic sound while the liver has a dull sound.
P: Non-tender, smooth.

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XIV. GENITALS
Patient Refused.

XV. EXTREMITIES
I: Extremities are proportion to the gross body structure, normal in color and
mobile. All body parts are present. Peripheral IV access at right arm with no
signs of phlebitis and infiltration.
P: Peripheral pulses were properly palpated.

C. LABORATORY/ DIAGNOSTIC EXAMINATIONS

I. Ultrasound of the Gallbladder

August 1, 2005

A. Gallbladder
Interpretation:
The gallbladder shows multiple shodiwng echogenicities. The the wall is thickened. Common
bile duct is not dilated.

Impression:
Cholelithiasis

B. Liver
Interpretation:
The liver shows normal size. No discrete mass lesion nor dilated intrahepatic ducts.

Impression:
Normal liver study

July 5, 2007
Interpretation:
The gall bladder shows multiple intraluminal echogenicities. The wall is not thickened.
Common bile duct is dilated.

Impression:
Cholelithiasis

Definition:
Is an ideal clinical tool for determining the source of abdominal pain. It can simplify the
differential diagnosis of abdominal pain, especially when pain and tenderness are present
over the site of disease. Even if ultrasonography reveals no obvious etiology, it can facilitate
diagnosis by excluding potentially life-threatening conditions. Emergency abdominal
ultrasonography is indicated for the evaluation of aortic aneurysm, appendicitis, and biliary
and renal colic, as well as blunt or penetrating abdominal trauma.

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Nursing resposibilty:
Pre procedure
1. Place the patient on NPO 6 hours prior to procedure
2. Have the patient wear comfortable, loose-fitting clothing for your ultrasound exam.
3. Inform the patient that the procedure is non invasive.

Post procedure
1. Cleanse the abdominal area applied with KY jelly using tissue paper
2. Reassess the patient’s current condition.
3. Position the patient comfortably

II. Endoscopic Retrograde Cholangiopancreatography (ERCP)

July 7, 2007 3:00 pm

Indication:
Jaundice

History:
Cholelithiasis/ Elevated Liver Enzymes

Clinical Diagnosis:
To Confirm Choledocholithiasis

Medication:
Dormicum 2 mg. DIPRIVAN 100 mg, Fentanyl 65 mcg

Findings:
Visualized portions of the esophagus, stomach and duodenum are unremarkable.
Papilla is small with overlying fold. No bile egress noted. Pancreatogram is normal. Attempts
to cannulate the CBD using various cannulas and maneuvers failed. Cholangiogram not
possible. No unplanned events.

Diagnosis:
Normal Pancreatogram
Cholangiogram not done.

Definition:
Endoscopic visualization of the common bile, pancreatic, and hepatic ducts with flexible
fiberoptic endoscope inserted into the esophagus to the duodenum. The common bile duct
and the pancreatic duct are cannulated and contrast medium is injected into the ducts,
permitting visualization and radiographic evaluation. It is done to detect extra hepatic biliary
obstruction, such as stones, tumors of the bile duct, strictures or injuries to the bile duct and
scelorosing cholangitis; intra hepatic biliary obstruction caused by stones or tumor; and
pancreatic disease, such as pancreatitis, pseudocyst, or tumor. It maybe combined with a
therapeutic biliary or pancreatic procedure, such as endoscopic sphincterotomy, biliary and
pancreatic stents, tissue biopsy or fluid cystology, or retrieval of retained gall stones.

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Nursing resposibilty:
Pre procedure

1. Assess for any allergies to iodine, seafood, or contrast media.

2. Ensure that the patient remains in NPO since midnight before the study.
3. Ensure that dentures are removed; instruct patient to gurgle and swallow topical
anesthetic to decrease gag reflex, as ordered.
4. Verify that the patient has a signed informed consent before sedation is given.
5. Establish intravenous access.
6. Administer antibiotic prophylaxis as ordered.

Post procedure

1. Monitor and document vital signs.

2. Observe for and report abdominal distention and signs of possible pancreatitis,
including chills, fever, pain, vomiting, and tachycardia.
3. Maintain NPO status until gag reflex returns.
a. Check for Gag reflex by applying gentle pressure on a tongue depressor placed
on the back of the tounge.
4. Monitor for signs of perforation and infection.
5. Monitor for Side effects of any medications received during the procedure.

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III. Biochemistry

BIOCHEMISTRY
JULY 5, 2007
NORMAL RESULT IMPRESSION SIGNIFICANCE
VALUES
Bilirubin 0 – 1.0 mg/dL 5.2 elevated Tolal bilirubin
Total concentrations are
elevated in the blood
either by increased
production, decreased
conjugation, decrease
secretion by the liver, or
blockage of the bile ducts.
Direct 0 – 0.3 mg/dL 3.7 elevated
Increased of Direct
Bilirubin
bilirubin is due to
common bile duct
obstruction caused by
stones.
Unconjugated 0.0 – 0.8 1.5 elevated
Bilirubin mg/dL Increased Unconjugated
bilirubin is caused by over
production of bilirubin
hemolysis or failure of
uptake of unconjugated
bilirubin by the liver or
impairment in the
conjugation process in the
liver cells.

ALP 38 – 128 u/L 275 elevated Indicates that the person’s

(Alk Phos) (K) bile ducts are somehow
blocked.

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BIOCHEMISTRY
JULY 9, 2007
NORMAL RESULT IMPRESSION SIGNIFICANCE
VALUES
ALT (SGPT) 11.0 – 66 U/L 487 elevated In some liver disease,
especially when the bile
ducts are blocked ALT is
increased.
Bilirubin 0 – 1.0 mg/dL 1.4 elevated Tolal bilirubin
Total (D) concentrations are
elevated in the blood
either by increased
production, decreased
conjugation, decrease
secretion by the liver, or
blockage of the bile
ducts.
Direct 0 – 0.3 mg/dL 0.7 elevated Increased of Direct
Bilirubin bilirubin is due to
common bile duct
obstruction caused by
stones.
Unconjugated 0.0 – 0.8 0.10 elevated
Bilirubin mg/dL Increased Unconjugated
bilirubin is caused by
over production of
bilirubin hemolysis or
failure of uptake of
unconjugated bilirubin by
the liver or impairment in
the conjugation process
in the liver cells.

ALP 50 – 136u/L 188 elevated Enzymes related to bile

(Alk Phos) ducts; often elevated
when the ducts are
blocked

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IV. Clotting time test
July 7, 2007 12:59 AM

Examination:
Prothrombin Time (control): 12.0 secs
Prothrombin Time (test) : 11.4 secs or 122%
INR: 0.93

Normal Values:
PT: 10-13 sec
International Normalized Ratio (INR): 1.0 – 1.4

Defintion:
Prothrombin time (PT) is a blood test that measures how long it takes blood to clot.

V. Surgical Pathology Consultation Report

July 8, 2007

Clinical diagnosis:
Cholelithiasis

Specimen:
Gallbladder with stones

Diagnosis:
Chronic cholecystitis with cholelithiasis

Gross microscopic description:

The specimen consists of previously opened gallbladder in its measuring 6.6x2x2cm. The
external surface is greenish to gray tan and glistening while the mucosa is green and velvety.

VI. Hepatitis Profile

July 10, 2007

Specimen:
Serum

Examination:
Hepatitis profile (renal)

Hepatitis B surface Antigen – non Reactive

(a negative result indicates that a person has never been exposed to the virus or has
recovered from acute hepatitis and has rid themselves from the virus)

Antibody to Hep B surface antigen - Reactive

(a positive result indicates immunity to Hepatitis B from vaccination or recovery
from an infection)

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Antibody to Hep C virus – non reactive
(a negative result indicates that a person has not been exposed to the virus)

Remarks: Total antibody to Hep B core antigen -REACTIVE

(0.065) cutoff:1
(indicates recovery from an infection and the person is not a carrier or
chronically infected)

D. SURGICAL PROCEDURE:

I. Cholecystectomy
July 7, 2007 11:50 PM

Findings and Immediate Post-Operative Condition:

Patient places in supine position under general anesthesia. Asepsis and antisepsis. Sterile
drapes applied. A RUQ incision was done carried down to the peritoneum. Gallbladder
identified isolated and ligated individually. 5mm stone removed from the cystic duct.
Intraoperative cholangiogram done which showed good egress of contrast material through
the non-dilated CBD to the intrahepatics and down to the duodenum, no filling defect noted.
Gallbladder dissected from the liver bed using electrocautery. Gallbladder delivered.
Hemostasis assured. Closure done in layers peritoneum and posterior fascia, vicryl 2-0,
continuous. Anterior fascia, vicryl 2-0, continuous. Subdermal, vicryl 4-0, inverted T, sterile
strips applied. Dressings applied/ patient tolerated the procedure.

Intra-op Findings:
Gallbladder measuring 9x4 cm with multiple tiny blackish stones, wall not thickened,
common bile duct and cystic duct dilated, no filling defect with good egress of contrast
material.

Definition:
A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this
procedure are open cholecystectomy and the laparoscopic approach. It is estimated that the
laparoscopic procedure is currently used for approximately 80% of cases. It is performed to
treat cholelithiasis and cholecystitis. In cholelithiasis, gallstones of varying shapes and sizes
form from the solid components of bile. The presence of stones, often referred to as
gallbladder disease, may produce symptoms of excruciating right upper abdominal pain
radiating to the right shoulder. The gallbladder may become the site of acute infection and
inflammation, resulting in symptoms of upper right abdominal pain, nausea and vomiting.
This condition is referred to as cholecystitis. The surgical removal of the gallbladder can
provide relief of these symptoms.

Nursing resposibilty
Pre operative

1. Determine if the patient knows reason for cholecystectomy, what the procedure
involves, and what to expect post operatively.
2. Patient must remain NPO, from midnight, the night before surgery and void before
surgery

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 3. Administer IV fluids before surgery to improve hydration status if the patient has been
vomiting.
4. Administer antibiotics for acute cholecystitis as ordered.
5. Perform Enema to clean the bowels as ordered

Post operative

1. Assess for:
a. Vital signs, level of consciousness
b. Level of pain
c. Intake and output
2. Promote ambulation to prevent thromboembolus, facilitate voiding, and stimulate
peristalsis.
3. Be alert for potential complications of incisional infection, hemorrhage, and bile duct
injury
4. Encourage deep breathing exercises and pain medications as ordered
5. Encourage to walk 8 hours after surgery to promote wound healing and prevent
infection.

II. Intraoperative Cholangiogram

JULY 08, 2007

Interpretation:
The visualized intrahepatic bile ducts are normal in size.
The common bile duct shows abnormal filling defects.
There is egress of contrast into the duodenum.

Definition:
Floursoscopic examination of the intrahepatic and extrahepatic biliary ducts after injection of
contrast medium into the biliary tree through percutaneous needle injection. It helps
distinguish obstructive jaundice caused by liver disease from that due to biliary obstruction,
such as from a tumor, metal clips, injury to the common bile ducts, stone within the bile
ducts, or sclerosing cholangitis. A biliary catheter may be left in place to drain the biliary tree,
called percutaneous transhepatic biliary drainage (PTBD). This reveals jaundice, decreases
pruritus, improves nutrional status, allows easy access into the biliary tree for further
procedures, and can be used as an anatomic landmark and stent at the time of surgery.

Nursing resposibilty:
Pre procedure

1. Assess for any allergies to iodine, seafood, or contrast media to determine need to be
pre medicated with anti histamines and steroids to prevent reaction.
2. Instruct on remaining NPO or having clear liquids from midnight before the
procedure.
3. Verify that patient has a signed informed consent before sedatives are given.
4. Establish IV line
5. Administer antibiotics prophylaxis as ordered

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Post procedure

1. Monitor and document vital signs and assess puncture site for bleeding, hematoma, or
bile leakage.
2. Check for and report signs of peritonitis from bile leaking into the abdomen: fever,
chills, abdominal pain and tenderness, and distention.
3. Continue Anti biotic prophylaxis per protocol
4. If the patient has a PTBD, monitor catheter exit site for bleeding or bile drainage and
monitor drainage in bile bag for color, amount, and consistency. The drainage initially
may have some blood mixed with bile but should clear within a few hours.
a. Report frank blood and/or blood clot that appear in the bile bag.
b. Large amounts of bile drainage may require fluid replacement
c. Maintain patency and security of biliary catheter; perform routine care and
dressing at catheter exit site.
d. Perform routine flashing of catheter as ordered.
e. Cut off end of biliary catheter to allow internal drainage of bile, if indicated.
f. Teach patient the care and flushing of biliary catheter and signs of
complications if indicated.

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