Intro Lab Results

3 I.

INTRODUCTION Gallstones develop in the gallbladder from crystals of either cholesterol or

bilirubin. Stones can be too small to be seen with the eye or can range from the size of grains of sand to the size of golf ball. There may be one or hundreds of stones in the gallbladder. At any point, stones may obstruct the cystic duct which leads from the bladder to the common bile duct and cause pain (biliarycolic) infection and inflammation (cholecystitis) or both. Stone in the gallbladder is the fifth leading cause of hospitalization among adults and accounts for 90% of all gallbladder and duct disease, seventy to eighty percent of patients’ gallstone remain asymptomatic throughout their lives. About 1-3 % of these patients exhibit symptoms in any year. Risk of developing gallstones increases with age. It afflicts 10-20% of adult population. Incidence is more common in women, with female ratio approximately 2.4. Women between the ages of 20 and 60 are twice likely to develop gallstones than men. Women are at risk because estrogen stimulates the liver to remove more cholesterol from blood and divert into bile. Gallstones usually remain asymptomatic initially. They start developing symptoms once the stones reach a certain size (>8mm).A main symptom of gallstones is commonly referred to as a gallstone attack, in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately thirty minutes to several hours. A victim may also encounter pain in the back, ordinarily between the shoulder blades or pain under the right shoulder. In some cases, the pain develops in the lower region of the stomach, nearer to the pelvis, but this is less common. Nausea and vomiting may occur.

4 The following objectives guided the researchers in this case study: a.) Patient Centered •

Our primary goal is to provide maximum patient care for the patient’s recovery.

•

To impart health teaching to the patient and other members of the family which may help them better understand the patient’s present condition.

b.) Nurse Centered •

To identify the patient’s problem associated with the disease.

•

To gain more information about the disease and the proper management for the patient suffering from this specific disease.

II. BIOGRAPHICAL DATA Name

:

VILORIA, MELO JANE LARA

Birth Date

:

August 31,1971

5 Age

:

36 years old

Gender

:

Female

Civil Status Address

Married :

San Pedro, Sta. Cruz, Ilocos Sur

Religious Affiliation :Roman Catholic

III. HISTORY OF PRESENT ILLNESS According to the patient, she felt something painful at her upper right abdomen. She was diagnosed at Candon Hospital and the results revealed that she has gallbladder stones. The medicines prescribed were unrecalled. The persistence of the

6 said condition made the family decide to seek consultation at Lorma Medical Center on September 12, 2007 at 9:17 in the morning. The Admitting Medical Doctor, Dr. Emilio V. Joven gave a clinical impression of Cholelithiasis. The patient is under the care of Dra. Hildegunda Santos during her confinement at Lorma Medical Center for 6 days.

IV.PAST HEALTH HISTORY

According to patient MJV, she had never been hospitalized in the past but

7 during her childhood, she suffered from chicken pox, measles, fever, cough and colds. As a typical Ilocana, she eats whatever food on the table, but most of it were salty and fatty foods like dried fish, pork and chicken barbecues. She was fond of eating salty foods like dried fish and drinks less than 8 glass of water per day. She consumed beverage drinks (coke 12oz) 3 bottles a day. She craved and ate fatty foods for approximately two weeks. She spent her idle time watching TV while eating salty foods. Two years ago, patient MJV experienced abdominal pain at the upper right quadrant accompanied by back pain categorized as cramping pain at the lumbar region. Furthermore, throughout the year, she also experienced an abdominal pain (upper quadrant) every after meal as well as severe back pain. She did not seek any medical attention and no medication taken as well because as stated by the patient, taking a rest would relieve the pain and she also though that the back pain was only due to fatigue. Two days prior to admission, again, she experienced severe back pains. Hence, decided to seek for consultation at Lorma Medical Center under the care of Dr. Emilio V. Joven (September 12, 2007). During the admission, patient MJV was experiencing an on

and

off

full

pain.

She

was

given

an

admission

diagnosis

of

Cholelithiasis/Cholecystitis and further she was confined. The following medications were prescribed:Ketomed 30 mg IV every 6 hours, Nubain. She was scheduled for Cholecystectomy on September 13, 2007 at 1:30 P.M

8

V. FAMILY HISTORY

Father: Martin Lara Illness: Cough

9 Headache Fever Mother: Melicia Lara Illness: Headache Sister: Mary Jane Lara Illness: Cough Fever Common colds Headache Grandfather: Bernardino Garcia Age: 80 years old Illness: Arthritis

VI. PERSONAL AND SOCIAL HISTORY Patient MJV is a 36 year old woman who was born by normal delivery on August 31, 1971 at Candon Hospital, Candon, Ilocos Sur. Their house is a Bungalow type with 3 bedrooms and a comfort room located inside their house. Their house is located 250m

1 0 away from the national road. She belongs to a nuclear type family. They disposed their garbage by compost pit and burning. They get their water source from jetmatic pump and use it for washing clothes, dishes and bathing purposes. They buy purified water for drinking. The patient admitted that she was fond of eating salty foods like dried fish and drinks less than 8 glass of water per day. She consumed beverage drinks (coke 12oz) 3 bottles a day. She craved and ate fatty foods for approximately two weeks. She spent her idle time watching TV while eating salty foods.

VII. REVIEW OF SYSTEMS/PHYSICAL ASSESSMENT Patient: MJV

Age: 36 years old

Sex: Female

Race: Filipino

Date and Time of P.E: September 12, 2007; 10:00 A.M.

Pre-Operative Examination

1 1 GENERAL APPEARANCE Posture and Gait: slouched, bent posture and coordinated movement Grooming and Hygiene: clean and neat Body and Breath Odor: no body odor or minor body odor

MENTAL STATUS Attitude: Cooperative Mood: Appropriate to situation Quantity/Quality and Organization of Speech: understandable and with coherence of thought I.

INTEGUMENTARY •

SKIN - Color: Dark brown - Uniformity of skin color: uniformed except palms and nail beds because they have lighter pigmentation - Appearance of skin: No pallor, no cyanosis

•

•

HAIR -

Growth over the scalp evenly distributed

-

Color: black

-

Hair thickness or thinness: hair is thick

-

Hair infestation: no lice and dandruff

NAILS -

Shape: flattened angle

1 2 II.

Nail bed color: light pink

HEAD •

Shape: rounded (normocephalic)

EYES -

Pupils are equally round and reactive to light

-

Both eyes are coordinated and move in uniform with coordinated alignment

•

•

•

III.

EARS -

Color: same as facial skin

-

Position: symmetrical

-

Hearing acquity: good hearing acquity

NOSE -

Symmetric and straight

-

Uniform in color

-

No discharge or bleeding

-

No tenderness

MOUTH -

Lips are slightly pink

-

Has complete set of teeth, white in color

-

Gums are light pink in color

NECK -

Neck Muscles: equal in size, the head is centered

-

Temperature: warm to touch

1 3 IV.

V.

VI.

Head movement: coordinated

THORAX AND LUNGS -

Chest is symmetrical

-

No tenderness, no masses

-

Absence of crackles and murmurs

ABDOMEN -

Skin: unblemished and uniform in color

-

Contour and Symmetry: Flabby

-

Auscultation: normal, audible bowel sounds

-

Palpation: Soft and no tenderness

EXTREMITIES - Upper and lower extremities: pulses are palpable, able to flex and extend - Absence of edema

VII. GENITALIA VII.

Not examined

RECTAL -

Not examined

1 4

VIII. ANATOMY & PHYSIOLOGY THE DIGESTIVE SYSTEM The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules, and it also has to excrete waste. Most of the digestive organs (like the stomach and the intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is

1 5 essentially a long, twisting tube that runs from the mouth to the anus, plus few other organs (like the liver and pancreas) that produce or store digestive enzymes. THE DIGESTIVE PROCESS The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules). After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements. Then, food enters the stomach which is a large, sac-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. After being in the stomach, food enters the jejunum, the duodenum and then the ileum of the small intestine. In the small intestine, bile (produced in the liver and stored in the bladder), pancreatic enzymes and other digestive enzymes produced by the inner wall of the small intestine help in the break down of food. After passing through the small intestine, food passes into the large intestines. Here, some of the water and electrolytes are removed from the food. Many microbes (like Bacteroides, Lactobacillus acidophilus, Escherichia coli and Klebsiella) in the large intestines help in the digestion process. The first part of the large intestine is called

1 6 cecum in which the appendix is connected, food then travels upward in the ascending colon, then travels across the abdomen in the transverse colon to the descending colon then to the sigmoid colon. Solid waste is then stored in the rectum until excreted via the anus. THE GALLBLADDER The gallbladder is a pear-shaped sac about 7-10 cm (3-4 in.) long. It is located in a depression on the posterior surface of the liver and usually hangs from the anterior margin of the liver. The functions of the gallbladder are to store and concentrate bile (up to tenfold) until it is needed in the small intestine. In the concentration process, water and ions are absorb by the mucosa of the gallbladder. When the level of cholecystokinin (CCK) increases, the smooth muscle in the wall of the gallbladder contracts and forces bile into the cystic duct and into the small intestine. When the small intestine is empty, a valve around the hepatopancreatic ampulla (ampula of Vater) closes, and the backed-up bile flows into the cystic duct to the gallbladder for storage

1 7

IX. PATHOPHYSIOLOGY

Dietary Influences (increased fat diet, inadequate fluid intake) Change in relative concentration of Bile components

Supersaturation of bile components (increased cholesterol, decreased bile salt and lecithin)

Formation of stones in the Gallbladder

Accumulation of Bile

Obstruction of cystic duct by the stone

1 8

Gastric Distention

Compression of nerve endings

Vomiting

RUQ pain

X. DIAGNOSTIC EXAMINATION Candon Hospital Name: Melo Jane Viloria Age: 36

Sex: F

X-RAY / ULTRASOUND REPORT Liver and spleen are within normal size and configuration. Hepatic and splenic echoes are homogenous. The intrahepatic ducts and splenic vessels within normal caliber. Gallbladder is normal in caliber measuring 64 x 34 mm, with multiple rounded shadowing dense echoes. The walls are unthickened. Pancreas is not visualized due to overlying bowel gasses. No free peritoneal fluid seen, within the Morrison's pouch. The kidneys are normal in position, size and contour. The central echo complexes are intact with homogenous cortical echoes. There is a rounded shadowing high echolevel density in the midcortical region, right kidney, measuring 12mm. Urinary bladder is sonographically intact. Unenlarged uterus with smooth contour and uniform mymetrial echoes.

IMPRESSION: >CHOLECYSTOLITHIASIS >Non-obstructing nephrolithiasis, right kidney

1 9 >Rest of the scanned organs are within normal. >Sonographic limits

Lorma Medical Center Laboratory Department CD1700 SPECIMENT DATA REPORT Specimen ID #: 26 Patient: VILORIA, MELO JANE

Analyzed: 09/12/07

TEST

RESULT

REFERENCE RANGE (Limit

WBC LYM MID GRAN

10.0 2.3 0.3 7.4

K/uL 23.2%L 2.9%M 73.9 %G

4.0 0.6 0.0 2.0

RBC HGB HCT MCV MCH MCHC RDW

4.46 12.1 36.8 82.6 27.1 32.9 14.4

M/uL g/dL % fL pg g/dL %

3.60 12.0 36.0 80.0 27.0 31.0 11.5

PLT

243 K/uL

BLOOD TYPE

“A”

3)

– – – –

11.0 4.1 1.8 7.8 – – – – – – –

K/ul 10.0 – 58.5%L 0.1 – 24.0%M 37.0 – 92.05G

6.00 M/uL 18.00 g/dL 55.0% 100.0 fL 31.0 pg 36.0 g/dL 14.5%

150 – 450 K/uL

2 0 Clotting Time = 3 minutes Bleeding Time = 2 minutes & 30 second CLINICAL SIGNIFICANCE: The result of patient MJV’s Blood Chemistry was within the parameters of normal range basing from the range provided by the agency (LMC).