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MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Boulevard


Metropolitan Park, Pasay City

In partial fulfilment
Of the Requirements of the
College of Nursing in
Related Learning Experience

Acute Calculous Cholelithiasis

Submitted by:
Caberte, Iris D.
Group CA5

Submitted to:
Rebekah Bullecer, RN MAN
MANILA DOCTORS COLLEGE
Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay city

I. ASSESSMENT

A. General Data

Resident’s Initials: L.V. Sex: female


Address: Imus Cavite
Age: 35 yrs. old Civil Status: Single
# of days in the Hospital: 10 Occupation: Pharmacist
Place of Birth: Muntinlupa City Date of Birth:September 11, 2010
Date of Admission: August 11, 2010
Order of Admission: Ambulatory, accompanied by husband
Informant: L.V. (Client), J.V. (Husband)
Date of History Taking: August 17, 2010

B. Chief Complaint

The client experienced abdominal pain in the right upper quadrant of the
abdomen with the pain scale of 6/10, as 10 being the highest. She describes it as sharp
and continuous pain. The pain radiates to the back. There were no associated
symptoms.

C. History of Present Illness

2 days prior to confinement, LV felt pain on the right upper quadrant of the
abdomen with the pain scale of 8/10 as 10 being the highest. She self medicate and
took Buscopan 1 tab twice. The pain was lessened from 8/10 to 6/10. She didn’t seek
her physician because the pain was tolerable.

1 day prior to confinement, she felt the same amount of pain. She still self
medicate with Buscopan 1 tab twice a day and the pain was lessened from 8/10 to
6/10. LV and his husband decided to take a leave from work to seek the attending
physician the following day.

1 hour prior to confinement, LV together with his husband went to Manila


Doctors Hospital for check-up on her attending physician and was advised for
admission.

D. Past History
1. Childhood Illness: Chicken pox (10 years old)
2. Adult Illnesses: None
3. Immunization: Unrecalled
4. Previous Hospitalization: None
5. Operation/s: None
6. Injuries: None
7. Medications taken prior to confinement: Buscopan 1 tab BID PO
8. Allergies: None
E. Systems Review- Gordon’s Eleven Functional Health Pattern
(August 18, 2010)

A. Health Perception- Health management

Prior to confinement, the client said that she has always been healthy these
past few months. She seldom gets cough or cold. She also mentioned “Ngayon lang
ako nahospital dahil sa sakit. Ayoko ng ganito.” She always has her annual physical
examination for her compliance in her work. She thinks that the cause of her illness is
due to eating too much junk food, drinking a little amount of water and too much soft
drink.

During her confinement, the client’s perception about her health has changed.
She also said, “Kelangan ko na talaga iwasan yung mga gusto kong pagkain alang
alang sa pamilya ko.” She also mentioned that she is always bothered because of the
pain she feels due to the incision. The client looks tired and not well rested. During
the interview, the client feels dizzy. “Nahihilo ako. Siguro dahil sa Augmentin.” as
verbalized by the client.

B. Nutritional-Metabolic Pattern

Prior to confinement, the client said that she always has a poor appetite.
“Mapili yung panlasa ko. Gusto ko sea foods, fish, pagkain na maaalat at samahan mo
pa ng soft drinks.” as stated by the client. She eats 3-4 times a day. For her breakfast,
she usually eats a cup of rice, viand of any kind and a cup of water. For lunch and
dinner, she eats a cup of rice, a serving of any kind of viand especially fish and a glass
of soft drinks. She sometimes has snacks in the afternoon like finger foods and junk
foods. She drinks 4 glasses of water a day. She rarely having nausea and vomiting.
She added “Nahihilo ako kapag kulob yung area tapos aircon lalo na sa bus. Kaya sa
bahay naming nakabukas yung binata pero may screen naman kaya walang
makakapasok na lamok.” Her vomit consumes 1/4 cup of the previous meals she ate
during that day. She has no discomfort in swallowing and has no restrictions in diet.
She does not have any problem regarding wound healing. She doesn’t have any dental
problems and she has no time for dental check-up.

During the confinement, the client eats the food served by the hospital and her
oral intake lessens up to 2-3 glasses per day. The client is on soft diet from August
15-17, 2010 then shifted to diet as tolerated on August 18, 2010.

C. Elimination Pattern

Prior to confinement, the client defecates twice a week. She observes brown
soft formed stool during defecation. She seldom felt constipated and didn’t do
anything about it. The client urinates 3-4 times a day with urine colour of yellow. She
does not have any discomfort in his elimination pattern.

During the confinement, the client urinates 7 times a day. The client
mentioned “Siguro dahil sa swero ko at parang maraming beses ako umihi sa isang
araw.” The client did not defecate.
D. Activity – Exercise Pattern

Prior to confinement, the client had no form of exercise other than walking,
work, and cleans the house. During her spare time, she sleeps. She stays at home
watching television.

During confinement, the client feels weak. She has a little energy that is why
she always lies on the bed. Her activity consists of eating, talking with her husband
and sleeping. She falls under the functional level of II and needs the aid of her
husband. She is encouraged to ambulate as ordered by her attending physician.

E. Sleep-Rest Pattern

Prior to confinement, the client sleeps depends on her shift in her work. In her
AM shift which is 6AM-2PM, the client sleeps at around 3 PM to 3 AM with a total
of 12 hours of sleep. In her PM shift which is 2PM-10PM, the client sleeps at around
11 PM to 6 AM with a total of 7 hours of sleep. In her NOC shift which is 10PM-
6AM, the client sleeps at around 7 AM to 5 PM with a total of 10 hours of sleep.
Sometimes, she had difficulty of going to sleep because of different sleeping pattern.
She does not take afternoon naps. She does not experience any nightmares. She also
said that she does not have snoring problems.

During confinement, the client said that she is slightly disturbed with nurses
monitoring her every hour.

F. Cognitive- Perceptual Pattern

Before hospitalization, the patient has no problems with her hearing and eye
sight. She neither wears eyeglasses nor hearing aid. She has no problem with her
memory. Decision making for her depends on the severity of the problem. She weighs
the decision with her husband for the best in their family. Sometimes she seek advise
with her friends. “Kahit sino naman humihingi ng advise sa friends diba?” She can
speak tagalong and English well.

During confinement, her vision and hearing did not change. She also gets a
little bit irritated due to her condition.

G. Self Perception- Self Concept Pattern

Prior to confinement, the client describes herself as a skinny and relaxed person. “Sa
lahat ng magkakapatid, ako lang yung pinakamapayat.” as stated by the client. The
client also mentioned that as much as possible, she does not want to get sick.
“Naiirita ako kapag meron akong nararamdaman na sakit.” She also said that she
does not lose hope because her husband is always there for her and she believes that
God will always be there for her.

During confinement, the client said thinks that she need to change her eating
habits. “Kelangan ko na talagang iwasan yung mga gusto ko kahit bawal. Para sa
ikabubuti ko naman din yun.” But then she still worries about her physical appearance
“Kelangan ko na rin magpataba at tanggapin yung mga pangyayari sa akin ngayon.”
H. Roles-Relationships Pattern

Prior to confinement, the client has a nuclear type of family which is


composed of her husband and daughter. Her husband works as a registered
pharmacist, and as the breadwinner of the family, he provides everything especially
the financial aspect. She said that her husband’s salary together with her salary is
enough to provide for them. The client and her husband take turns of taking care of
their only child depending on their shift. The client mentioned that she and her
husband always talk especially when it comes to major decisions in life. She added
“Depende kung mas maganda yung desisyon niya e di siya yung masusunod. Kung sa
akin, e di yung akin. Give and take ika nga.” She also said that she and her family
have a harmonious relationship with each other. The client also mentioned that she
has friends and they meet occasionally.

During confinement, the client is supported by her husband “parati ko kasama


ang asawa ko para alalayan ako. Hindi na siya umuuwi samin. Napakasupportive nya,
Hayun yung anak ko naman nasa bahay binilin ko muna sa ate ko.”

I. Sexuality- Reproductive Pattern

Prior to confinement, she recalled her menarche when she was 12 years old.
She also said that her period lasts for about three days. She consumes three sanitary
pads a day which were fully soaked and bright to dark red in color. Sometimes she
experience dysmenorrhoea during her period. The client also said that she and her
husband are both sexually active. She also mentioned that they do not use any family
planning method.

J. Coping-Stress Tolerance Pattern

Prior to hospitalization, the client said that there is no crisis going on within
her family. Whenever they have problems concerning with their children they fix it
right away. “Wala kaming away na left hanging. By the end of the day, ngkakabati
kami.” She also believes that her husband is the most helpful person in talking things
over. Sometimes she feels stressed from work but when she gets home she sleeps.

During hospitalization, that client said that she is not stressed out because they
surgery is done. She also said that she also follow her physician’s orders because she
wants to get well immediately. “Kelangan ko nang magrecover ng mabilis para
makapagtrabaho na ako at makapiling ko na rin ang anak ko.”

K. Values Belief Pattern

Prior to confinement, the client hear mass every Sunday with her family. She
added “Pero madalas hindi buo yung pamilya. Minsan ako at ang anak ko lang.
Minsan silang mag-ama lang.” She prays before she goes to sleep, she asks for
forgiveness and strength to overcome her problems. Included in her prayers was her
family. The client’s religion is Roman Catholic.

During confinement, the client said that being in the hospital does not interfere
with his religious practices. They still pray regularly and still has hope for her
recovery. They believe that everything will be alright.

F. Family Assessment
EDUCATIONAL
NAME RELATION AGE SEX OCCUPATION
ATTAINMENT
L.V. Client 35 F Pharmacist College graduate
J.V. Husband 37 M Pharmacist College graduate
Elementary
J.V. Daughter 11 F None
student

G. Heredo – Familial Illness


Maternal: Cholelithiasis, Heart attack
Paternal: None

H. Developmental History
Theory (Theorist) Age Developmental Task Patient’s Description
Psychosexual 13 yrs. Genital Stage The client has a husband and a
(Sigmund Freud) old and . child. She can freely express her
above feelings as a woman and is
happily married. She and her
husband are both sexually active
and do not use any family
planning method.
Psychosocial 19-40 Intimacy vs. Isolation The client has established her
(Erik Erikson) yrs. old own family and is financially
stable. She is close with her
sisters and friends.
Cognitive 12 and Formal Operations Stage The client does not have a hard
(Jean Piaget) above time in making decisions. She
weighs the decision with her
husband for the best in their
family. Sometimes she seeks
advice with her friends.
Moral 13- 35 Conventional Level (Social The client is aware that people
(Kohlberg) yrs. old Approval) have different opinions and that
respect should still be given to
them. “Kaya give and take kami
ng asawa ko kung kanino mas
maganda yung desisyon. Minsan
humihingi ako ng opinion sa
mga friends ko.”
Spiritual 21- 45 Stage 4 Individuative- The client is a Roman Catholic
( James Fowler) yrs.old Reflective faith and has her own point of view
when it comes to religion. She
goes to church every Saturday
with her family. She prays
before going to sleep.
I. Physical Examination
Date of history taking: August 18, 2010

Height: 4’10” Weight: 38.18 kg


Actual Height: 4’10”

Body Mass Index:

Weight in kg.
BMI = ___________________

(Height in meters) ²

38.18 kg
BMI = ___________________

(1. 47 m) ²

BMI = 17.67 kgs/m²= indication of within the Underweight

Desirable Body Weight


(Tannhauser’s Method of DBW Computation)

DBW = (height in cm - 100) - (10%[ht in cm – 100])


DBW = (147 cm – 100) – [10% (147 cm – 100)]
47 – [10%(47)]
46 – 4.7
DBW = 41.3 kg

Vital Signs

BP: 120/80 mmHg PR: 80 bpm


RR: 22 cpm T: 37.1 oC

General appearance:
- Ectomorph
- Client is clean in her overall hygiene
- No halitosis or body odor
- Cooperative and able to respond
- Understandable and clear tone of speech
- Client’s organization of thought makes sense
- Able to maintain attention span
- Restless appearance
-Jackson Pratt Drain was attached to the RUQ incision site
-T-tube was attached to RUQ incision site near common bile duct

A. Skin
I: - Fair skin complexion
- Hair is evenly distributed on the patient’s skin

- No lesions
P: - Good skin turgor
- Smooth and moist skin

- Warm to touch

- Uniform temperature on all areas

- No palpable nodules or masses

B. Nails
I: - Well rounded, convex curvature
- Pinkish in color
- Short and clean nails
- Nail bed approximately 160 degrees
- Intact epidermis
P: - Smooth texture
- Good capillary refill (2 seconds)

C. Skull and Face


I: - Normocephalic
- Symmetric facial features and movements
- Hair is black in color
P: - Head has no masses and deformities
- Absence of nodules and masses
- No pain upon palpation

D. Eyes
I: - Eyebrow is evenly distributed and skin is intact
- Eyebrows are symmetrically aligned with the ears
- Eyelashes are equally distributed and curled outward
- Eyelids are intact, no discharges, no discoloration, or excessive tearing
- Pupils: equally round, reactive to light and accommodation.
- Sclera is white in color
P: - No tenderness felt in her eyes
- No edema in lacrimal and nasolacrimal duct

E. Ears
I: - Color is even and consistent with the rest of the skin
- Aligned with the outer canthus of eye
- Symmetric and proportional to the head
- Ear canal is pinkish, clean, with scanty amount of cerumen
- No discharges
- No swelling on both ears
- Good hearing acuity
P: - Pinna recoils after it is folded
- No tenderness

F. Nose
I: - Symmetrical to the face
- No underlying deviation, discharge or flaring
- Uniform in colour
- Nasal septum intact in midline
- Pink mucosa
P: - No areas of tenderness, inflammation and lumps upon palpation.
- Non-tender and absence of masses on frontal and maxillary sinuses.

G. Mouth and Oropharynx


I: - Pink in colour and soft lips
- Able to purse lips
- No dentures
- Symmetry of contour
- Moist, pinkish mucosa
- No bleeding, swelling and inflammation of gums
- Uvula positioned midline of soft palate
- Tongue midline without deviation, moves freely, no tenderness
- No swelling, symmetrical tonsils

H. Neck
I: - Head is in the midline
- Able to move with no difficulty
- Proportion to body structure
- Coordinated smooth movements
- Thyroid gland not visible
- No discomforts
- No swelling
P: - No vein engorgement and scars
- Lymph nodes not palpable
- Visible pulsation of the carotid artery

I. Spine
I: - Spine lies straight without lateral deviation.
P: - No presence of tenderness masses and lumps.

J. Thorax / Lungs
I: - Color is consistent with the rest of the skin
- Symmetrical chest expansion
- Quiet, rhythmic and effortless respirations
- Spontaneous, non-labored breathing.
Pa: - Skin is intact and uniform in temperature
- Equal anterior and posterior thorax excursion

- No tenderness
- No masses
Per: - Not performed
A: - Normal breath sounds

K. Cardiovascular / Heart
I: - Visible pulsation on the carotid artery
- Jugular veins not distended
P: - No lifts or heaves
- No pulsations on aortic and pulmonic areas
- Peripheral pulses are bilaterally equal (radial, brachia, carotid, popliteal).
- No lifts or heaves
A: – S1 is louder in tricuspid and mitral valves
- S2 is louder in aortic and pulmonic valves. No S3 or S4 sounds.
- No S3 and S4 sounds

L. Breast -The patient refused

M. Abdomen
I: - Contour was round and bilaterally symmetrical Position of umbilicus
was midline and inverted
- Incisions found on in the RUQ.
- With JP drain, intact, and maintained on negative pressure with
serosanguinous output
- With T-tube, patent, with dark green output.
A: - The patient refused
Pe: - The patient refused
Pa: - The patient refused

N. Extremities:
I: - Uniform in color
- Equal size of muscle on both sides of the body
- IV is attached on right metacarpal; intact with no signs of infiltration
and phlebitis.
- Lower extremities are flaccid
- Able to move upper extremities
- No tremors or contractures
P: - Absence of tenderness on the upper and lower extremities

N. Genitals
- The patient refused to have a physical examination in her genital area on
the day of interview, but according to the patient, she has no rashes or skin
lesions in the area. The patient doesn’t have difficulty in urinating and no
tenderness felt in the area.

G. Rectum and Anus


- The patient refused to have a physical examination in her rectum and
anus on the day of interview, but according to the patient, she has no
rashes or skin lesions in the area.

II. Personal/Social History

Habits: Watching TV, Shopping, Rank/Order in the family: Mother


Sleeping Travel: None
Vices: None Educational Attainment: College
Lifestyle: Sedentary graduate
Social Affiliation: None Occupation: Registered pharmacist

Client’s usual day like:


The client sleeps depends on her shift in her work. In her AM shift which is 6AM-
2PM, the client sleeps at around 3 PM to 3 AM and does her daily morning routine
like taking a bath, prepare the food for the family, eat breakfast, oral care, and get
ready for work. In her PM shift which is 2PM-10PM, the client sleeps at around 11
PM to 6 AM and does her daily morning routine like taking a bath, prepare the food
for the family, eat breakfast, oral care, and bring her daughter to school. In her NOC
shift which is 10PM-6AM, the client sleeps at around 7 AM to 5 PM and fetches her
daughter from school, prepares dinner for the family, eats dinner, takes a shower, and
prays before going to bed.

III. Environmental History


Before confinement the patient lives at a single storey house in a village. Their
house is well constructed. Services such as electricity, water supply, and regular
garbage collection are present. Their house is accessible to health care facilities such
as Health Centre, Hospital, and Pharmacy. Commercial Establishments is also
accessible. Means of transportation such as jeepney, bus, taxi, pedicab, and tricycle
are present.

IV. O.B. GYNE History

Menarche (age): 12 years old When: 2nd year high school


Amount & characteristics: 3 pads of napkin per day
Duration: 3 days
Associated symptoms: None
Deliveries: G: 1 P: 1
OB Score: T: 1 P: 0 A: 0 L: 1

V. Pediatric History (Not Applicable)


VII. Laboratory Tests

ULTRASOUND (August 12, 2010)


Liver is normal in size, configuration and echopattern. No focal mass lesion.
Intrahepatic bile ducts are not dilated. Common bile duct is norml in caliber and
measures 0.5 cm.

Gallbladder has length of 10 cm and a greatest transverse dm of 4.1 cm with


unthickened wall. Several lithiases are noted intraluminally ranging in size from 0.5
cm to 0.8 cm with length of 3.5 cm. Cluster of mobile non-shadowing medium level
echoes are also noted. Intraluminally with length of 2.3 cm. At least 2 lithiases
measuring 0.9 cm and 1.1 cm are seen in gallbladder neck. Cystic duct is 1.2 cm in
diameter with 0.8 cm lithiases. Sonographic Murphy’s sign is evident over the
gallbladder area.

Pancreas is normal in size and coutoure with no evident focal mass lesion. Pancreatic
duct is not dilated.

Impression:
 Distended gallbladder with multiple lithiases and thick bile sludge/non shadowing
lithiases, as described.
 Dilated cystic duct with lithiases is also considered.
 Normal liver, intrahepatic bile ducts and pancreas.

HEMATOLOGY (August 11, 2010)

Normal
Components Results Interpretation
Values
Normal, Hgb has the unique
property of combining reversibly
with oxygen and is the medium by
which oxygen is transported within
140-175
Hemoglobin 146 the body. It is iron-containing
g/L
protein of RBC’s. It takes up oxygen
as blood passes through the lungs
and releases it as blood passes
through the tissues.
Normal, Hematocrit represents the
Hematocrit 0.42-0.50 0.44 percentage of red blood cells found
in 100 ml of whole blood.
Normal, RBC is a cellular
Red Blood Cell 4.50-5.90 x component of blood involved in the
4.9
Count 1012/L transport of oxygen and carbon
dioxide.
Increased, Elevate WBC could
White Blood 4-10.50 x
13.01 indicate presence of infection,
Cell Count 109/L
inflammation, tissue damage, etc.
Neutrophil 0.36-0.66 0.74 Increased, Elevated neutrophils can
indicate stress, infection, inflamed
tissue, etc.
Decreased, This could indicate
Lymphocyte 0.24-0.44 0.18
viral, bacterial, or fungal infection.
Normal, Monocytes are considered
Monocyte 0.02-0.12 0.06 to be the largest among the
leukocytes
Decreased, This indicates stress
Eosinophil 0.02-0.05 0.01 reactions, treatment with
corticosteroids, or infection.
Platelet Count 200 – 400 375 Normal has a good clotting process.
MCV 83 – 101 fL 89.2 Normal, the size of the RBC is
normocytic.
MCH 27 -31 pg 29.8 Normal, average weight of the
hemoglobin in RBC.
MCHC 31.5 – 34.5 33.4 Normal, average hemoglobin
g/L concentration per unit volume of
RBC.
RDW 39 – 46 fL 13.3 Decreased, It means that the cells
are actually more uniform in size.

Peripheral blood:
Smear: Normocytic, normochromic

HEMATOLOGY (August 14, 2010)


Normal
Components Results Interpretation
Values
Decreased, This can be an
140-175
Hemoglobin 127 indication of bleeding,
g/L
malnutrition, or anemia.
Decreased, This can be
indication of anemia due to loss
Hematocrit 0.42-0.50 0.39
of blood during surgery or
nutritional deficiency.
Decreased, This can indicate
Red Blood Cell 4.50-5.90 x
4.35 anemia due to blood loss which
Count 1012/L
can lead to fatigue.
Increased, Elevate WBC could
White Blood 4-10.50 x
16.52 indicate presence of infection,
Cell Count 109/L
inflammation, tissue damage, etc.
Increased, Elevated neutrophils
Neutrophil 0.36-0.66 0.87 can indicate stress, infection,
inflamed tissue, etc.
Decreased, This could indicate
Lymphocyte 0.24-0.44 0.06 viral, bacterial, or fungal
infection.
Normal, Monocytes are
Monocyte 0.02-0.12 0.07 considered to be the largest
among the leukocytes
Platelet Count 200 – 400 298 Normal has a good clotting
process.
MCV 83 – 101 fL 90.3 Normal, the size of the RBC is
normocytic.
MCH 27 -31 pg 29.2 Normal, average weight of the
hemoglobin in RBC.
MCHC 31.5 – 34.5 32.3 Normal, average hemoglobin
g/L concentration per unit volume of
RBC.
RDW 39 – 46 fL 12.8 Decreased, It means that the
cells are actually more uniform in
size.

COAGULATION & HEMOSTASIS (August 15, 2010)


Normal
Components Results Interpretation
Values
Protime
Delayed, Prolonged PT may due to
Prothrombin time 11.65-14.60
26 bile duct obstruction or Vitamin K
– Patient secs
deficiency.
APPT
Activated Partial
Thrombopl 26.66 –
33.6 Normal has a good clotting function.
astin – 34.55 secs
Patient
Activated Partial
26.66 –
Thromboplastin – 29 Normal has a good clotting function.
34.55 secs
Control

SAMPLE SERUM (August 15, 2010)

Normal
Components Results Interpretation
Values
Increased, This may indicate hepatitis,
excessive alcohol intake, liver or gallbladder
ALT/SGPT 9 - 52 u/L 122
inflammation, fatty liver or presence of
gallstones in bile ducts.
Increased, This may indicate same as with
AST/SGOT 14-36 u/L 88
ALT/SGPT.
Increased, It is the sum of the direct and
0.18 – 1.29
Total Bilirubin 4.83 indirect bilirubin. This may indicate bile
mg/dL
duct obstruction.
Increased, It is the bilirubin that has been
taken up by the liver cells and conjugated to
0 – 0.29
Direct Bilirubin 4.26 form the water-soluble bilirubin
mg/dL
diglucuronide. This may indicate bile duct
obstruction.
Indirect Bilirubin 0 – 1.11 0.57 Normal, It is the lipid-soluble form of
mg/dL bilirubin that circulates in loose association
with the plasma proteins.

ERCP: Stone extraction, pappilotomy (August 16, 2010)


Findings: scope inserted up to second portion of the duodenum. (+) bile in the
duodenum. Bulging papilla noted. CBD cannulated showing a 0.7 cm filling defect at
the distal CBD. Wire guided papillotomy done. About 1 cm cut performed. Alliance
lithotripter was used to crush and remove the stone. Several passes using 0.8 cm
balloon was done with note of good flow & bile of contrast.

XRAY RESULT (August 16, 2010)


ERCP
Scout film shows an endoscope tip in the right upper abdominal quadrant. A
Jackson-Pratt drain is likewise seen.

Initial infusion of contrast through the cannulated ampulla opacified the


normal calibered common bile duct with a filling defect at its distal third, likely a
lithiases measuring 0.7 cm. A biliary tube is noted. Multiple lucent foci are seen at the
middle to distal common bile duct, representing air bubbles. The normal calibered
common hepatic duct, intrahepatic ducts and their radicles were also opacified. No
filling defect is noted therein. A guidewire was inserted. Several balloon and basket
sweeps were administered, extracting a lithiases. Post scope radiography reveals the
partially opacified billiary structures and T-tube and JP drain in place.

BLOOD TYPING (August 16, 2010)


ABO Typing: “O”
Rh typing: Positive

B. On-going Appraisal

August 11, 2010, LV was admitted to Manila Doctors Hospital under the service of
Dr. A. She was conscious and coherent and has spontaneous non-labored breathing.
Initial vital signs were taken. CBC was done. Hooked IVF #1 D5NR 1L to run for 8
hrs and #1 D5NM + 30 KCl to run for 12 hours at the right hand; intact and infusing
well. Given Disflatyl (chewable) 1 tab prn and the abdominal pain was lessen from
the pain scale of 6/10 to 5/10. Encourage deep breathing exercises. For abdominal
ultrasound tomorrow was requested by the attending physician. NPO instructed. CBG
monitoring was done with result of 63 mg/dL and 76 mg/dL respectively.

August 12, 2010, Ultrasound was done. The patient is for cholecystectomy possible
IOC tomorrow at 1PM. The consent was signed for the procedure and for anaesthesia.
Initial dose of Ceftriaxone (Xtenda) IV 1 gm q12 and HNBB IV 1 amp prn for
abdominal pain was given. CBG monitoring was done with result of 80 mg/dL, 87
mg/dL, and 89 mg/dL respectively.

August 13, 2010, CBG monitoring was done with result of 93 mg/dL and 82 mg/dL
respectively. The patient was brought to operating room for the scheduled
cholecystectomy at exactly 1PM.

Procedural report:
• Supine with padding at the posterior right upper quadrant
• Sterile field prepared
• Oblique right sub costal incision, carried down to peritoneum
• Intra-operative assessment
• CHOLECYSTECTOMY (same procedure)
• Perform transcystic intra-op cholangiogram
• Perform Kocher maneuver (release the lateral and posterior attachments
of the 2nd portion of duodenum)
• Palpate the CBD, pancreas and duodenum
• Site of choledochotomy identified and skeletonized
• Traction suture placed laterally and medially using silk 4-0
• Horizontal incision is made between the sutures
• Irrigation with saline done proximally and distally to flush the stones out
• CBD stones removed using Randall forceps
• No.3 Bakes dilator is passed in the distal CBD and the tip is visualized
thru the anterior wall of the duodenum
• T-tube is inserted with limbs cut short
• Choledochotomy is closed around the T-tube
• Saline is injected to T–tube to check for leaks
• Completion cholangiogram done to confirm the absence of stones
• Irrigation with NSS
• Hemostasis done
• Complete count
• T-tube is brought out thru a separate stab wound
• Layer by layer closure
• Peritoneum and post. rectus sheath - continuos interlocking -Vicryl-0
• Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0
• Skin closed subcuticularly using vicryl 4-0.
• Dry Sterile Dressing

Transferred in from OR s/p cholecystectomy IOC CBDE. Received patient with IVF
ongoing #4 D5NM 1L to run for 12 hrs at 900 cc and #1 pNSS 1L to run for 12 hrs at
full. With dressing at post-operative site, JP drain maintained on negative pressure
and T-tube with drainage bag. The paitient vomited and was given Zofran IV 4mg q8
for nausea. Other initial doses medications given: Ketorolac IV 30mg q8, Celebrex
PO 20mg 1 cap BID, Tramadol IV 50mg q6.

August 14, 2010, The patient is on general liquids diet, as ordered. CBC was done.
CBG monitoring was done with the result of 80 mg/dL, 89 mg/dL, and 67 mg/dL
respectively. Febrile with temperature of 37.6 C; TSB was done. Initial doses of
Pantoloc IV 40mg OD, Dolcet 1 tab TID, and Cerebrex (Celecoxib) 20mg/cap BID
for pain were given.

August 15, 2010, The patient is on soft diet. AST, ALT, Bilirubin, PTT done. CBG
monitoring was discontinued. For ERCP tomorrow at 12:30 PM. The consent was
signed by the patient. NPO post light breakfast instructed. Cerebrex (Celecoxib)
20mg/cap BID for pain was discontinued.
August 16, 2010, The patient was for transfusion of 4 unit of FFP before and during
the procedure. She was brought to Endoscopy department department for ERCP at
12:30 PM.

Procedural report: ERCP: Stone extraction, pappilotomy


Flexible endoscope inserted up to 2nd portion of duodenum. There was presence of
bile in the duodenum. Bulging papilla noted. CBD cannulated showing a 0.7 cm
filling defect at the distal CBD. Wire-guided papillotomy done. About 1cm cut
performed. Alliance lithotripter was used to crush and remove the stone. Several
passes using 0.8cm balloon was done with note of good flow and bile of contrast.

Recommendations: Disflatyl 2 tabs TID for 3 days the 1 tab prn; Buscopan 10mg TID
for 3 doses, then 1 tab TID prn

Transferred in from Endoscopy department s/p ERCP. Received patient with IVF
ongoing #6 pNSS 1L to run for 10 hrs and side drip #3 FF “u” FFP with serial # of
MDH 0695-0-10. To follow side drip #4 FFP w/ serial # MDH 2067-0-10; properly
typed & x-matched. With dressing at post-operative site, JP drain maintained on
negative pressure with serosanguinous output and T-tube with drainage bag. Resume
soft diet. Complaint of stomach pain with pain scale of 8/10. Given Disflatyl PO 2
tabs TID PRN. Constant with temperature of 39.8 C. Given Aeknil IV 1 amp stat. RR
was 34 cpm but no complaints of DOB. Deep breathing exercise instructed.

August 17, 2010, Discontinued medications: Ceftriaxone (Xtenda) IV 1gm q12,


Zofran IV 4mg q8 for nausea, Pantoloc IV 40mg OD, Ketorolac IV 30mg q8,
Celebrex 20mg 1 cap BID, and Tramadol IV 50mg q6. Intermittent fever with
temperature of 38.3 C. Paracetamol 500mg 1 tab q4 if T > 37.8 C. Initial doses of
Vitamin K 1 tab 10mg OD and Augmentin IV 1.2gm q8 given. Encouraged the
patient to ambulate and increase oral fluid intake.

August 18, 2010, On diet as tolerated as ordered. Shifted from Augmentin IV 1.2gm
q8 to Augmentin 1 tab 625mg BID. She complaint of nausea after taking the 1st dose
of Augmentin. Augmenin 1 tab 625mg BID was discontinued and initial dose of
Ciprofloxacin 500mg 1 tab BID for 5 days as ordered. For possible discharge.

C. Discharge Plan

M – edications
Continue ongoing medications: Dolcet 1 tab TID for moderate to severe pain,
Paracetamol 500mg 1 tab q4 if T > 37.8 C, Vitamin K 1 tab 10mg OD,
Ciprofloxacin 500mg/tab BID for 5 days, Disflatyl 2 tabs TID for 3 days the 1
tab prn; Buscopan 10mg TID for 3 doses, then 1 tab TID prn.

E – xercise
1) You may feel tired for the first couple of weeks after your operation.
2) Take a nap when you feel tired.
3) Walking around the house, office work, climbing stairs or riding in a car is fine as
soon as you feel able.
4) Do NOT do any hard physical activity, heavy lifting (nothing heavier than 10
pounds) or sports for four weeks after surgery.
5) Sexual activity is fine as soon as you are comfortable.
6) Do NOT drive a car if you are taking pain medicine and until the soreness is gone.

T – reatment
1) Daily incision care:
a. Gently wash the skin around your incision daily with mild soap and water.
b. Change dressing with sterile gauze daily if there is one on your incision.
c. Keep the dressing dry and clean.
d. You may take a shower (even if there is a drain in place), unless your
doctor gives you different instructions.
e. Do not sit in a tub for a bath until the incision is closed and the drains are
taken out.
2) Encourage the patient to have her lifestyle and diet modified.
3) Encourage the patient to ambulate.
4) If you have constipation (not being able to have a bowel movement take one
tablespoon of Metamucil each day for the first few weeks to help with this
problem.

H – ealth Teachings
1) Increase the oral fluid intake.
2) Advise to take antibiotic on full course. Even if you feel well, DO NOT stop
taking them until they are gone. If you develop diarrhea notify your physician.
3) Encourage the patient to ambulate.
4) Avoid fatty foods.
5) If there’s a JP drain, instruct the patient to measure the amount in the drain every
8 hours and the aseptic technique of closing the drain. Refer to the physician the
amount you recorded per day.

O – PD
Refer to Physician/Psychiatrist for OPD follow-ups. Remind patients that
regular check-ups are important to ensure that the patient condition is constantly
monitored by the doctor.

D – iet
1) Limit the intake of saturated fat
2) Avoid alcoholic beverages.
3) Eat smaller amounts of food during a single meal
4) Eat around 5 or 6 smaller meals a day instead of 2 or 3 usual meals.
5) Take vitamin and mineral supplements and bile salts to aid the process of
digestion.

S – igns and symptoms


Inform the physician if you feel the following signs and symptoms:
1) Skin looks jaundice (yellowish color to your skin or the sclera).
2) Chills or fever greater than 38.3C.
3) Redness, swelling, increasing pain, pus or a foul smell at the incision site.
4) Dark or rust colored urine.
5) Bowel movements that look clay colored or no color instead of brown.
6) If pain is not relieved by pain killers.
7) If the abdomen swells.
8) Persistent nausea or vomiting.