CASE STUDY 1: GROUP 2A

Patient's code name: Mr. R

Age: 55 y/o
Address: Brgy Balara Quezon City
Date of Birth: September 3, 1965
Nationality: Filipino
Civil Status: Married (living separately)
Occupation: Mining Engineer (DENR)
Sex: Male
Religion: Roman Catholic
Ward: Medical Surgical Ward
Bed no.: 1704
Date of Admission: March 4, 2021
Time: 7:00 am
Vital signs upon admission:
BP: 120/70 mmHg RR: 19 cpm
Temp.: 37.1 °C PR: 66 bpm
Admitting Diagnosis: Calculous Cholelithiasis
Attending Physician: Dr. J Dela Cruz
Type of Admission: Ambulatory

FAMILY BACKGROUND AND HISTORY

Mr. R, a 55 year-old male, was born in Bohol on March 3, 1965. He is currently residing at Brgy

Balara Quezon City. They are 7 in the family including his parents. He is the third child among the five

children. Our patient has completely received immunization since he was a child.

Upon interview, Mr. R said that they had a family history of the same type of disease,
which is the Diabetes Mellitus. He mentioned that within the family, they had 2 cases from his
mother’s side and on his father side of the family. His aunt from his father’s side was also
diagnosed with cholelithiasis.

LIFESTYLE: ACTIVITIES

Mr. R described how his workplace is similar to his home in terms of stress. He
verbalized that there are times when he is stressed and there are others when he the situations can
let him relax.

When asked about how he usually spends his days, Mr. R was able to formulate a
schedule that would describe his activities of daily living. He would wake up at 6:00am. The first
thing he would do is take a bath. Right after taking a bath, he takes his breakfast. After brushing
his teeth, he rides his transportation service to his office. By 8:00am, he arrives in his office.
Here, he usually does paper work, participates in interviews and meetings, records data in his
office computer and, on some occasions, perform field work as a supervisor. After work, he has
the option to either go home directly (7:00pm arrival) or have a night out with his friends from
work. There are times that he chooses to go out and drink; the most would be two times in a
week. For every time that he goes out to drink, he would consume an average of 2 bottles. If he
chooses to go out and spend the night outside the house, he’d get home by around 12:00
midnight and onwards.
LIFESTYLE: DIET

Since his grade school years, Mr. R was fond of eating all kinds of “lechon.” He is also
fond of drinking carbonated beverages and he drinks alcoholic beverages occasionally. After he
was diagnosed with Diabetes, he started eating less lechon and more vegetables, whole grains
and fish. During the interview, Mr. R was asked if he knows any more changes in his diet. He
only shrugged and said he was still unsure of how his diet will change now that he is missing a
gall bladder.

HISTORY OF PATIENT’S PAST ILLNESS

Mr. R was diagnosed of having Diabetes Mellitus type II last 2007. He was advised by
his doctor to be more particular on his diet (to eat more vegetables and fruits and not to eat too
much fatty foods) and do some exercise so that his diabetes will not get complications. He was
also diagnosed of having gallstone last 2018 at a community hospital, through ultrasound on the
hepato-biliary tree. He recalls being instructed to take buscopan and co-amoxiclav after being
diagnosed.

Mr. R had also mentioned that he has a history of hypertension. This wasn’t evident
during the group’s assessment on Mr. R. However, Mr. R remembers that he had gone to several
hospitals and doesn’t remember where he was diagnosed with hypertension. Mr. R does
remember this happened in the year 2007. Since then, he had been taking anti-hypertensives like
Pritor and Lipitor.

HISTORY OF PATIENT’S PRESENT ILLNESS

Mr. R started experiencing a sharp RUQ pain in the year 2006. He suspected a
disturbance in the stomach, so he took Kremil-S and Buscopan. As an additional self-treatment

for the pain, he frequently ate “lugaw” and he took a lot of rest. Eventually, the pain went away
but it came back three years later. In 2007, the year he was diagnosed with Type 2 Diabetes
Mellitus, he experienced the same sharp RUQ pain just like the one in 2006. Knowing that his
previous self-treatment was effective, he used it again, with an additional advice from his doctor:
drinking plenty of apple juice. Again, the pain went away as expected. However, Mr. R did not
know that his condition was actually getting worse. Two years after the second incidence, the
pain returned. Still not alarmed as he was in the previous years, Mr. R still used his self-
treatment for the pain in 2010. Mr. R shared that after 2010, he experienced the pain every year
already. He also shared that every time, he used the same self-treatment.

By March 3,2021, he experienced the worst pain of them all. He shared that his self-
treatment methods was able to ease the pain, but it surprisingly took longer than it did before. By
this time, he decided to have himself checked by a doctor. He was admitted and advised
Laparoscopic Cholecystectomy.

PHYSICAL ASSESSMENT

GENERAL SURVEY

He was received lying on bed awake, conscious and coherent. He has an ongoing IVF of
D5NSS 1 liter regulated at 140cc/° infusing well at R metacarpal vein at 300cc level. He weighs
72 kilograms with a height of 5’6”. He has an endomorphic body structure. Calculation of his
BMI reveals that he is overweight (25.62kg/m2) He was responsive and cooperative when asked.

VITAL SIGNS

BP – 120/80

PR – 62 beats per minute

RR – 22 breathes per minute

Temp. – 36.9°C

SKIN

Our patient has a tan complexion. He has a good skin turgor as skin goes back to its
previous state after being pinched and with a capillary refill of 2 seconds. He has dry skin with a
rough texture. Nails were properly trimmed and no traces of dirt were noted.

HEAD

Our patient’s head is normocephalic. Presence of hair was noted in the head and in the

upper and lower extremities. Lesions, bleeding and bruises were not seen upon inspection. His
hair is evenly distributed and majority of hair color is grey with several strands of black and
white hair. No signs of dandruff and lice noted.

EYES

Eyes are symmetrical with each other. The cornea is moist and white in color. The iris appears to
be black on both eyes. Pupils are equally round and reactive to light and accommodation with a
pupillary size of 2 mm. He needs reading glasses when reads small texts. His eyebrows are thick
and eyelashes are evenly distributed along the margin of the eyelids; both eyes move in unison;
no signs of scratches on both eyes and no discharges noted.

EARS

The shape of the pinnaes is oval and with no discharges noted. Upper margin of the
pinnaes is in line with the outer canthus of the eyes. Ears are firm and non-tender. Signs of
lesions, lacerations, swelling and bruises were not seen upon inspection. He was able to repeat a
sentence when it was softly said behind his ears, which reveals that he does not have any hearing
problems.

NOSE

External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.
Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are present upon
inspection. Nasal septum is not deviated. Both nostrils are patent. No signs of tenderness were
noted. Patient was able to distinguish the smell of rubbing alcohol while eyes were closed.

MOUTH

Lips are dry with minimal cracks. Teeth are not complete with dentures noted upon
inspection. A total of 3 cavities were also seen upon inspection of the teeth. Gums and buccal

mucosa are pinkish in color. Tongue is in the midline of the mouth. Tonsils are not inflamed. No
signs of inflammation and laceration on the uvula. Bleeding, ulceration and swelling were not
seen upon inspection. Patient was on soft diet and was able to drink coffee and medications with
no dysphagia.

NECK

The neck of our patient can move easily without any difficulty, which includes right and
left lateral, right and left rotation, flexion and hyperextension. Neck can properly support the
head. No signs of enlargement and masses on the thyroid. Carotid pulse is palpable. No signs of
swelling or enlargement of the lymph nodes. No deformities noted.

CHEST AND LUNGS

Chest muscle expansion during inspiration and relaxation during expiration are
symmetrical and painless. There were no presence of scars and lesions. He was not in respiratory
distress. Respiratory rate is 18 cycles per minute and rhythm was regular. Breath sounds were
clear on both lungs indicating that he is free of cough or colds.

ABDOMEN

Patient’s abdomen is globular in shape, soft, and flabby. Bowel sounds are hyperactive
with 17 sounds counted within one full minute. A dull pain was felt by the patient in the
umbilical area and worsens upon palpation.

GENITO-URINARY

Patient refused to be assessed on his genital area. However, patient verbalized no pain or
difficulty upon urination and defecation. Average urine output of patient was 31 cc/hr. His total

output for 8 hours was approximately 250cc.

 UPPER EXTREMITIES

Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted on the
bones of the wrist and fingers. No deformities and swelling noted. He could freely move his
shoulders. No structural deviations noted.

LOWER EXTREMITIES

Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and bend
without any difficulty. No signs of deformities, lesions, lacerations, bruises and bleeding were
seen upon inspection. Patient does not have any difficulty ambulating.

DOCTOR’S ORDERS

DATE DOCTOR’S ORDER

March 4, 2021 • Pls. admit under my service
7am • TPRq4˚
• NPO post midnight
Wt: 73 kg • Labs: CBC, Blood typing, platelet count, Urinalysis,
Temp: 36.6 °C
Creatine,FBS,B1 B2, Alk phosphate, Protime, APTT, Chest X-ray
BP: 120/80
PA view. ECG
RR: 18
• Schedule patient for laparoscopic cholecystectomy
PR: 86
HGT: 120 mg/dl • Please secure consent
• Inform OR & Dr. Santos for anesthesia
• Refer to Dr. Pasia for CP clearance
• Start IVF D5LR 1L to run at 120cc/o prior to transport
• Give cirprobay 200mg IVTT NOW (ANST)
• Refer accordingly

 DIAGNOSTIC EXAMS
Urinalysis
PE CE
Color: yellow Glucose: (-)
Transparency: clear Albumin: (-)
Rxn: 6.0
Specific Gravity: 1.005
Microscopic Examination
Pus cells: 0.1/hpf Uric Acid -------
RBC: 1.3/hpf calcium Oxalate ------
Epithelial cells (+) Triple phosphate -------
Mucous threads (-) Amorphous Urates
Yeast cells ------- Phosphate -------
Hyaline Cast ------ Others ------
Fine granular cast -------
Coarse granular cast -------

X-Ray Report
The lung fields are clear
The heart is not enlarged
Great vessels are not unusual
Diaphragm and costophrenic sulci are intact.
No other remarkable findings.

Impression: Normal Chest findings

 Ultrasound Report
The liver is normal in size with mild diffuse increase in tissue attenuation. No focal
solid or cystic lesions demonstrated. The intra-hepatic ducts are not dilated. The widest antero-
posterior diameter of the common duct is about 2.4mm.
The gall bladder is adequately distended with slightly thickened walls measuring up to
5.0mm. There is a 1.7cm intra-luminal echo exhibiting posterior sonic shadowing but no
dependent mobility in the gall bladder fundus.

Impression:
Mild Fatty liver

Calculous Cholecystitis

Hematology

Result Unit Reference:

Hemoglobin 133 g/dl M: 140 - 170

F: 120 - 150

Erythrocytes 4.29 10^12/L 4.0 - 6.0

Leukocyte 6.9 10^9/L 5.0 - 10.0

Segmenters 0.53 % 0.45 - 0.65

Lymphocyte (P) 0.39 % 0.20 - 0.35

Monocyte (P) 0.06 % 0.02 - 0.06

 Eosinophils 0.02 % 0.02 - 0.04

Hematocrit 0.41 -- F: 0.38 - 0.4

M: 0.40 - 0.60

thrombocyte 177 10^9/L 150.0 - 450.0

Blood typing “B” Rht

 Coagulation Result Form

Result Reference Range:

Protime

Patient 13.8 sec 11.5 - 14.5 sec

INR 0.99 Normal: 1.0 - 1.2

PTPA 96.4 Therapeutic: 2.0 - 3.0

Control 13.9 sec

APTT

Patient 35.6 sec 24 - 36 sec

Control 30.2 sec

APTT MIXING

1°INCUBATION

Patient
-- sec
Control
-- sec

CORRECTED APTT

Patient -- sec Index: less than 12-corrected

Control -- sec Index: less than 16-not

corrected

 Blood Chemistry

Test Name Result Normal Value Unit

Creatinine 99.6 H 53.0 - 97.6 Mmol/l

Bilirubin T 7.6 0.0 - 18.8 Mmol/l

Bilirubin O 1.2 0.0 - 4.3 Mmol/l

Alkaline Phosphate 142 64 - 306 U/l

Magnesium 0.94 0.80 - 1.00 Mmol/l

Others:

Calcium -- 1.13 - 1.32 Mmol/l

Chloride -- 95 - 108 Mmol/l

Potassium 2.73 3.5 - 5.3 Mmol/l

Sodium 140.1 135 - 148 Mmol/l

Magnesium -- 0.8 - 1.0 Mmol/l

Normal Value LDL: 0 - 4.73 mmol/l

Normal Value Globulin 28 -31 g/l

Normal Value A/G Ratio 1.5 - 2.4 ratio