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III. PATIENT PROFILE Name: Age: Gender: Nationality: Civil Status: Religion: Address: Date and Time Admitted: How Admitted: Attending physician: Occupation: Hospital Plan: Source of Information:

M.D. 44 y/o Female Filipino Married Roman Catholic Quezon, City July 6, 2007; 3:00 PM Wheelchairborne De Ocampo, Sherrie Isabel Querubin Police Officer Individual 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 Contraceptives: none LMP: July 5, 2007 Family History: GI disorder: Heart Disease:

Abortion = 0 Live birth = 1

Father, Mother 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: Skin Color: Height and Built: Weight by appearance and measurement: Posture, Motor Activity, and Gait: Dress, Grooming, and Personal Hygiene: Odors of Body or Breath: Facial Expression: Speech: b. Vital Signs: Blood Pressure: Respiration Rate: Pulse Rate: Temperature: Pain Scale:

130/90 mmHg 22 breaths per minute 94 beats per minute 36.5 °C 6/10

c. Mental Status Appearance and Behavior: Speech and Language: Mood: Thought and Perceptions: Cognitive Functions:

With mild restlessness Slightly jaundiced 163 cm; proportionate limb 64 kg; fat Good posture, normal motor activity, normal gait Wears loose clothing, well groomed, good personal hygiene No body odor, no halitosis With facial grimace No speech defect, no hoarseness of voice

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: P:

II. NAILS I: P:

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

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

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III. HAIR I: P:

Thick and evenly distributed. 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:

VI. EARS I:

VII. NOSE I: P:

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. 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. The patient’s nose is proportion to the face. The nasal bridge is aligned. The mucous membranes are pinkish. 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. 5

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: P:

The patient’s spine has a normal curvature. 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 VALUES Bilirubin 0 – 1.0 mg/dL Total

Direct Bilirubin

Unconjugated Bilirubin

ALP (Alk Phos)

RESULT

IMPRESSION

SIGNIFICANCE

5.2

elevated

Tolal bilirubin concentrations are elevated in the blood either by increased production, decreased conjugation, decrease secretion by the liver, or blockage of the bile ducts.

0 – 0.3 mg/dL

3.7

elevated

0.0 – 0.8 mg/dL

1.5

elevated

38 – 128 u/L (K)

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Increased of Direct bilirubin is due to common bile duct obstruction caused by stones. 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.

elevated

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Indicates that the person’s bile ducts are somehow blocked.

BIOCHEMISTRY JULY 9, 2007 NORMAL VALUES ALT (SGPT) 11.0 – 66 U/L

RESULT

IMPRESSION

SIGNIFICANCE

487

elevated

In some liver disease, especially when the bile ducts are blocked ALT is increased. Tolal bilirubin concentrations are elevated in the blood either by increased production, decreased conjugation, decrease secretion by the liver, or blockage of the bile ducts. Increased of Direct bilirubin is due to common bile duct obstruction caused by stones.

Bilirubin Total

0 – 1.0 mg/dL (D)

1.4

elevated

Direct Bilirubin

0 – 0.3 mg/dL

0.7

elevated

0.0 – 0.8 mg/dL

0.10

elevated

50 – 136u/L

188

Unconjugated Bilirubin

ALP (Alk Phos)

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. elevated

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Enzymes related to bile ducts; often elevated when the ducts are blocked

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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