http://www.scribd.

com/doc/7158166/Draft-Case-Study-Choledocholithiasis 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. Lukes 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 wouldnt 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.
Patients 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: Alert, conscious, with guarding behavior Speech and Language: Speaks with clarity, fluent in speaking tagalog/ english Mood: With anxiety due to pain, with guarding behavior Thought and Perceptions: Coherent, with organization of thoughts, no hallucinations Cognitive Functions: Memory intact, oriented to time, place, and person
D. Regional Examination: I. SKINI:

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 patients 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 patients 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 patients spine has a normal curvature.

P:

There is absence of masses or lumps.

XI. CHEST AND LUNGS I:

The patients 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 07/09/07 07/06/07 07/08/07 0/09/07

given Metoclopramide (Plasil) 10 mg (3 times) given Metoclopramide (Plasil) 10 mg (once) D5NR 1L x 10 hrs consumed 07/07/07 Post Op: D5NR 1L x 8 hrs consumed 07/09/07 D5Nm 1L x 8 hrs revised D5NR 1L x 10 hrs D5NM 1L x 10 hrs T/C 07/10/07

Intravenous Fluids:

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)

Ar co x i a Dose: 90 mg 1 tablet (only if there is pain) 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.

E-xerc ise

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. Surgical Wound Care Instruct patient to comply with the given diet. (Comprehensive health teaching for patients 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. Follow up on July 18, 2007 at Dr. De Ocampos clinic; 10am Look for Amador Robert Sy. No special diets or other precautions are needed after surgery.

T-reatment

H- ealth Teaching

O- PD Follow-up

D-iet

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 100.4F), 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)

ULTRASOUND of GALL BLADDER, LIVE