Acknowledgement

We would like to express our profound gratitude to the following that in one way or another
helped us to complete this case study:

To Mrs. M.D. for being the subject of this study and for being cooperative during our
assessment and interview.
To all the staff & physicians of St. Luke’s Medical Center, for imparting us their
knowledge on becoming a professional staff nurse of the institution. And most especially, for
being patient and welcoming us during our rotation.
To our Clinical Instructor, Ms. Scatllana Ragrag, for supporting and sharing her
positive criticism that molded us into being an effective and assertive nurses.
To our family, for the unconditional and infinite love, support, encouragement and
inspiration.
To us, for working as a group, carrying our assigned task with ease and
professionalism. This wouldn’t be possible without the help of each one of us. Thanks for
working as one and for the friendship and fond memories that we shared.
And finally, to Almighty God, who has been there since the beginning of our time,
who was with us all along, coordinating our minds to focus on the study. Truly, everything is
nothing without you, Father.
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 Oampo, 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”

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: Chronic Calculous Cholecystitis (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
PHYSICAL EXAMINATION
Date Taken: 07 / 06/ 07 ( 1:30 PM )

A. General Survey:
Apparent State of Health:
Signs of Distress: with mild restlessness
Skin Color: Jaundice
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: 80 beats per minute
Temperature: 36 °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, with guarding behavior
Coherent, with organization of thoughts, no
hallucinations
Memory intact, oriented to time, place, and person

D. Regional Examination:

I. SKIN
I: Jaundice, there is 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).
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. There is
no obvious deformity seen in the external eye structures, with yellowish
sclerae (icteresia)
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.
 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
sound:22 per minute, no bruit.
Pe: The abdomen has a tympanic sound while the liver has a dull sound.
P: Non-tender, smooth.
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.

IV. ANATOMY AND PHYSIOLOGY

The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated
structures) that are involved in the production and transportation of bile. The transportation of
bile follows this sequence:
1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the
liver through the right and left hepatic ducts.
2. These ducts ultimately drain into the common hepatic duct.
3. The common hepatic duct then joins with the cystic duct from the gallbladder to form
the common bile duct, which runs from the liver to the duodenum (the first section of
the small intestine).
4. However, not all bile runs directly into the duodenum. About 50 percent of the bile
produced by the liver is first stored in the gallbladder, a pear-shaped organ located
directly below the liver.
5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the
duodenum to help break down the fats.
Functions of the biliary system:
The biliary system's main function includes the following:
• to drain waste products from the liver into the duodenum
• to help in digestion with the controlled release of bile
Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that
is secreted by the liver cells to perform two primary functions, including the following:
• to carry away waste
• to break down fats during digestion
Bile salt is the actual component which helps break down and absorb fats. Bile, which is
excreted from the body in the form of feces, is what gives feces its dark brown color. The
gallbladder is about 7-10 cm long in humans and appears dark green because of its contents
(bile), rather than its tissue. It is connected to the liver and the duodenum by the biliary tract.

• The liver is located in the upper right-hand portion of the abdominal cavity, beneath
the diaphragm, and on top of the stomach, right kidney, and intestines. Shaped like a
cone, the liver is a dark reddish-brown organ that weighs about 3 pounds.

• The cystic duct connects the gallbladder to the common hepatic duct to form the
common bile duct.

• The Common bile duct then joins the pancreatic duct, and enters through the
hepatopancreatic ampulla at the major duodenal papilla.

• Gallstones (cholesterol stones or pigment stones) form in the gallbladder over many
years. They can sometimes travel into the common bile duct, causing a blockage.

If the common bile duct is blocked, this then obstructs the whole of the biliary
drainage system as opposed to a blockage further up. Hence there is nowhere for the
bile to go but up and the patient becomes jaundiced since certain waste products
(bilirubin) are absorbed back into the blood stream. Furthermore there can be
potentially fatal complications of infection of the biliary tree (cholangitis) and acute
pancreatitis.
MEDICATION PROFILE:

Epidural Morphine Sulfate 0.02% = Freq: RTC Q12 x 3 doses; Strength: 10 ml

Lamiracoxig (Prexige) 400 mg PO OD x 3 days
Cefuroxime (Zegen) 500 mg PO Q12
Lansoprazole (Prevacid) 30 mg PO OD ac
Cefoxitin 1gm IV Q8
Pantropazol 40 mg IV OD
Ketoprofen (Oridis) + 100ml PNSS 100mg IV Q8 (-)ANST RTC x 3 doses
Monowel 1gm IV Q8 (ANST)
Plasil 1 amp IV

Stat Meds:
07/08/07 given Metoclopramide (Plasil) 10 mg (3 times)
07/09/07 given Metoclopramide (Plasil) 10 mg (once)

Intravenous Fluids:
07/06/07 D5NR 1L x 10 hrs consumed 07/07/07
07/08/07 Post Op: D5NR 1L x 8 hrs consumed 07/09/07
D5Nm 1L x 8 hrs revised
0/09/07 D5NR 1L x 10 hrs
D5NM 1L x 10 hrs T/C 07/10/07

Pre-anesthesia Evaluation:
History of Physical Illness: Jaundice and Abdominal pain
PMH: Hospitalized in 2007 for typhoid (-) sequalae
(+) Pre-ecclampsia
(-) HPN, (-) DM, No Known Allergy

Record of Operation:
Date: July 7, 2007
Surgeon: Dr. Amado
First Assist: Dr. Cabrera
Anesthesiologist: Dr. Cua
Anesthetic: Epidural
Pre-op Diagnosis: Cholelithiasis
Operative Diagnosis: same
Material: Forwarded to laboratory for examination of gallbladder stones
Operations performed: Cholecystectomy with I.O.C.

Description of Operation techniques (to include incision, drainage, sutures ):

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.

LABORATORY:

Endoscopic Retrograde Cholangio Pancreatography Report

Request Date: 07/ 07 / 2007

Indication: Jaundice
History: Cholelithiasis / Elevated Liver Enzymes
Clinical Diagnosis: T/C Choledocholithiasis
Medication: Dormicum 2mg, Diprivan 100mg, Fentanyl 65mcg
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.
Diagnosis:
Normal Pancratogram.
Cholangiogram not done.
John Arnel N. Pangilinan, MD (Endoscopist)

DISCHARGE INSTRUCTION / HEALTH TEACHING

Attending Physician: De Ocampo, Sherrie Isabel Querubin
Date: 07/11/07
Send home meds/ drugs and instruction on administration

Discharge Planning

M- edications
• Prevacid
Start date: 07/12/07
End date: 07/18/07
Dose: 30 mg 1tablet ( 1 tab once a day, 30 minutes before breakfast for 1 week )
• Cefuroxime
 First dose: 07/09/07
Last dose: 07/15/07
Dose: 500 mg 1tablet (1 tab every 12 hours for 5 days)
• Arcoxia
Dose: 90 mg 1 tablet (only if there is pain)
E- xercise
• Teach patient about deep breathing and controlled coughing execises.
Deep Breathing Exercise
> While on sitting position, place palms across from each other, down and
along lower borders of rib cage to feel the rise and fall movement.
> Inhale fully through the nose, hold for 2 – 3 seconds and exhale slowly
through the mouth.
Controlled Coughing Exercise
> Splint the surgical wound with pillow.
> Take a deep breath, hold for 3 seconds, and cough deeply 2- 3 times.

• Encourage bed exercises.

> Frequent gluteal and quadriceps muscle setting exercise during the day help to
prepare the client for later ambulation.
• Instruct patient to turn frequently when lying every two hours.
T- reatment
• Surgical Wound Care

H- ealth Teaching
• Instruct patient to comply with the given diet. (Comprehensive
health teaching for patient’s diet: c/o Dietary.)
• Surgical Wound Care.
Keep the dressing clean and dry. May wash the wound with sterile normal saline
water, then apply antibacterial ointment or povodine iodine (betadine) ointment,
and change the dressing daily.
• Teach patient about deep breathing and controlled coughing exercise to avoid pressure
on the wound.

O- PD Follow-up
• Follow –up on July 18, 2007 at Dr. De Ocampo’s clinic; 10am
Look for Amador Robert Sy.
D- iet
• No special diets or other precautions are needed after surgery.

Eat regular, balanced meals

Eat regular meals that contain some fat. Eat plenty of whole grains and fiber, and have
regular servings of food that contain calcium (found in green, leafy vegetables and milk
products). Limit saturated (animal) fat and foods high in cholesterol.

S- igns and symptoms

 Watch out for:
• Infection
> Any redness extending from the wound or yellow drainage from the area,
worsening pain, severe swelling, loss of sensation and warmth over the wound.

• Call your doctor if you have worsening pain, spreading redness around the site,
bleeding from the wound, fever (temperature greater than 100.4°F), or other concerns.

• Go to a hospital's emergency department if you have bleeding from the site that will
not stop with gentle pressure, if you have a thick discharge (pus) from the wound, or if
you have a high fever.

Final Diagnosis:
Obstructive Jaundice probably secondary to Choledocholithiasis with recent passage
Chronic Calculous Cholecystitis

Operation:
Cholecystectomy with Intraoperative Cholangiogram (IOC)
 DIAGNOSTIC RESULTS

ULTRASOUND of GALL BLADDER, LIVER

AUGUST 01, 2005
INTERPRETATION:

GALL BLADDER: the gall bladder shows multiple shadowing echogenicities. The walls are
thickened. Common duct is not dilated.

Impression: Cholelithiases

LIVER: The liver shows normal size. No discrete mass lesion nor dilated intrahepatic
ducts.

Impression: Normal Liver

ULTRASOUND of GALL BLADDER

JUNE 22, 2007
INTERPRETATION:

The gall bladder shows multiple intraluminal echogenicities. The wall is not thickened.
Common duct is not dilated.

Impression: Cholelithiases

Endoscopic Retrograde Cholangio Pancreatography Report

July 7, 2007
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.

OPERATIVE 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.
 LABORATORY RESULTS

BIOCHEMISTRY
JULY 5, 2007
NORMAL RESULT IMPRESSION REMARKS
VALUES
Bilirubin 0.2 – 1.3 5.2 elevated Bilirubin concentrations
Total mg/dL (K) are elevated in the blood
either by increased
production, decreased
conjugation, decreased
secretion by the liver, or
blockage of the bile
ducts.
Direct 0 – 0.4 mg/dL 3.7 elevated Conjugated
Bilirubin (K) hyperbilirubinemia is
caused by obstruction of
the biliary ducts, as with
gallstones or
hepatocellular diseases
such as cirrhosis or
hepatitis
Unconjugated 0.1 – 1.1 1.5 elevated
Bilirubin mg/dL (K)
ALP 38 – 128 u/L 275 elevated Indicates that the
(Alk Phos) (K) person’s bile ducts are
somehow blocked.

BIOCHEMISTRY
JULY 9, 2007
NORMAL RESULT IMPRESSION REMARKS
VALUES
ALT (SGPT) 11.0 – 66 U/L 487 elevated Detects liver injury
(D)
Bilirubin 0 – 1.0 mg/dL 1.4 elevated
Total (D)
Direct 0 – 0.3 mg/dL 0.7 elevated
Bilirubin (D)
Unconjugated 0.0 – 0.8 0.7 normal
Bilirubin mg/dL (D)
ALP 50 – 136u/L 188 elevated
(Alk Phos) (D)
SURGICAL PATHOLOGY CONSULTATION REPORT

JULY 9, 2007

Clinical diagnosis: Cholelithiasis

Specimen: gallbladder with stones

Diagnosis: Chronic cholecystitis with cholelithiasis

Gross microscopic description: the specimen consist 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.

CLINICAL IMMUNOLOGY AND SEROLOGY

JULY 10, 2007
Specimen: Serum
Examination:
Hepatitis profile (renal)

Hepatitis B surface Antigen – non Reactive

Antibody to Hep B surface antigen - Reacive(18.8 mlU/ml)

Antibody to Hap C virus – non reactive

Cutoff: 9.99
Remarks: Total antibody to Hep B core antigen -REACTIVE