BIOGRAPHIC DATA

NAME: M.V.R
AGE: 28 years old
GENDER: Female
DATE OF BIRTH: October 10, 1986
PLACE OF BIRTH: Talavera, Nueva Ecija
RELIGION: Iglesia Ni Cristo
STATUS: Married
NATIONALITY: Filipino
PRIMARY DIALECT: Tagalog
EDUCATIONAL ATTAINMENT: College graduate
CHIEF COMPLAINT: On and off abdominal pain
Reason for seeking health care and current understanding of health:
C
O
L
D
S
P
A

- Intense, dull pain

- 2 days prior to admission;
- Right upper quadrant and epigastrium area
- 30 minutes or less
- intolerable pain
- the pain worsens after eating
- No associated factors

PAST MEDICAL HISTORY

Childhood Illnesses: Client M.V.R experienced common illnesses such as colds, cough,
and fever during her childhood.
Immunization: When the client was asked of her vaccinations during childhood, the
patient verbalized Sa pagkakaalam ko kumpleto naman ako ng bakuna.
Major Illness:The client stated that she did not have any major illness that leads to
hospitalization. She only mentioned the time of hospitalization when she gave birth to
her first child.
HISTORY OF PRESENT ILLNESS
The client experienced abdominal pain every time after eating. The pain was
being felt in the abdominal area particularly in the epigastric and right upper quadrant
area. The client stated that she did not seek for professional advice until the pain
became intolerable. The patient experienced intolerable pain two (2) hours prior her
admission last October 26, 2014. The client is now 1-day postoperative. The client
experiences mild to moderate pain on the incision site with a pain scale score of 6/10.
9

As she verbalized medyo mahapdi na yung inoperahan sakin, Kung out of 10 nasa 6
na siya ngayon. The client is observed to be showing some facial grimacing while
describing the pain on her post operative wound.
FAMILY HISTORY
The client has no family history of hypertension, allergies and diabetes mellitus.
The clients father was diagnosed before of Choledocholithiases. This is the only
hereditary disease known by the patient that runs in the family.

SOCIAL HISTORY
The client is a non-smoker, non-alcoholic beverage drinker. The client stated that she
does not have any vices.

10

PHYSICAL ASSESSMENT (Upon admission done by Resident on Duty)

Vital Signs: BP: 120/70, RR: 20cpm, PR: 72bpm, Temperature: 36.5 C
ORGAN

NORMAL

METHODOFASSESSMENT FINDINGS

General Appearance

Conscious, coherent, cooperative

attitude and behavior.
Bulbar conjunctiva is clear with
tiny vessels visible; palpebral
conjunctiva is pink with no
discharge; sclera is blue-white.
In white skin: Light to dark pink;
sun-tanned areas, white patches
(vitiligo)
In dark skin: Light to dark brown,
lighter colored palms, soles, nail
beds and lips.
Chest symmetry is equal,
intercostal spaces are even and
relaxed. Symmetrical expansion.
Bronchovesicular breath sounds.

Inspection

Eyes

Skin

Chest and Lungs

Inspection and palpation

Inspection

Conscious
and
Coherent
Pink
palpebral
conjunctiva

Negative
jaundice;
negative erythema

Inspection,
auscultation

palpation Symmetrical
chest
expansion,
clear
breath sounds, no
retractions

Heart

Heart Rate: 60- 100bpm; regular. Auscultation

Distinct end of S1 and beginning
of S2 with nothing in between.

Normal rate, negative

murmurs

Abdomen

Rounded or flat. High pitched, Inspection, Auscultation, Soft, flabby epigastric

irregular gurgles 5-35 times perm Palpation
tenderness,
inute(normoactive
bowel
normoactive
bowel
sounds); present equally in all
sounds
four quadrants. No bruits, no
venus hums, no friction rubs.
Soft, non-tender, no masses and
no tenderness
Full and equal peripheral pulses. Palpation
Full
and
equal
peripheral pulses

Extremeties

11

PHYSICAL ASSESSMENT (1 day Post-operative)

Vital Signs: BP: 110/80, RR: 24cpm, PR: 90bpm, Temperature: 36.0
Pain scale score of 6/10
ORGAN

NORMAL

General Survey

Conscious, coherent, cooperative Inspection

attitude and behavior.

Face

Symmetric or slightly asymmetric Inspection

facial features

Eyes

Bulbar conjunctiva is clear with Inspection and palpation

tiny vessels visible; palpebral
conjunctiva is pink with no
discharge; sclera is blue-white.

Skin

In white skin: Light to dark pink; Inspection

sun-tanned areas, white patches
(vitiligo)
In dark skin: Light to dark brown,
lighter colored palms, soles, nail
beds and lips.
Chest symmetry is equal, Inspection
intercostal spaces are even and auscultation
relaxed. Bronchovesicular breath
sounds.

Chest and Lungs

METHODOFASSESSMENT FINDINGS

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Oriented to time, place

and
person.
Cooperative behavior;
The
patient
experiences mild to
moderate pain due to
the operation. The
patient is showing
guarding
behavior
toward the post
operative site and
showing slight facial
grimace.
The
client
has
symmetric
face
contour, the eyebrows
were
evenly
distributed with black
in color. The color of
the eyes was black,
and symmetrical. The
ears were symmetrical
Pink
palpebral
conjunctiva

The client has fair

colored
skin.
No
significant signs of
inflammation, pruritus
or damage to skin.
and The client breathes
with symmetrical chest
expansion,
clear
breath sounds,

Heart

Heart Rate: 60- 100bpm; regular. Auscultation

Distinct end of S1 and beginning
of S2 with nothing in between.

Abdomen

Rounded or flat. High pitched, Inspection, Auscultation, The patient has post
irregular gurgles 5-35 times per Palpation
operative
wound
minute(normoactive
bowel
covered with sterile
sounds); present equally in all
dressing and with tfour quadrants. No bruits, no
tube connecting to a
venus hums, no friction rubs.
drainage bag located
Soft, non-tender, no masses and
on
right
upper
nontender.
quadrant
of
the
abdomen. The post
operative wound is dry
and intact. The t-tube
is draining to dark
yellow green output.
With active bowel
sounds. There is mild
to moderate pain on
the
post-operative
wound.

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The clients heart rate

is 89bpm.

GORDONSS FUNCTIONAL PATTERN

HEALTH PERCEPTION HEALTH

MANAGEMENT PATTERN

The patient described herself as already an unhealthy person

even before hospitalization. When the patient was asked to rate her
present health condition from 1 to 10 (10 being the highest and 1 being
the lowest), she responded 6 lang. She expounded and verbalized Sa
kalagayan ko ngayon, ang score ko lang ay 6, kasi nasa ospital ako
ngayon at naoperahan ako kahapon. The client also mentioned that
she had surgery because she was diagnosed to have stones in her
gallbladder. When the client was asked about her perception of a
healthy person, she stated malakas ang pangagatawan, nagkakasakit
man pero hindi yung malalala at naooperahan. The client also expanded
that her present condition affected her normal daily activities because
she can no longer perform to fullest extent because of the postoperative
wound. The client also expressed her concern regarding her
postoperative as she verabalized Ngayon lang ako naoperahan, hindi ko
pa alam kung pano maglilinis ng sugat na ganito. And according to the
client she does not consult a health professional until she cant handle or
manage her illness.

NUTRITIONAL AND METABOLIC

PATTERN

Before the hospitalization the client does not take any vitamin
supplements or any herbal supplements. The client was eating three
major meals (breakfast, lunch and dinner) a day. The client does not
have any difficulty eating on time. She usually consumes bread and juice
for snacks. The client describes her diet high in fat and sodium. The
foods the client cannot consume are foods and drinks made with blood
due to her chosen religion. The client stated mahilig ako sa mga pinirito
at medyo madalas akong kumakain ng junk foods at sa mga Jollibee.
The client does not have any difficulty in tolerating certain kind of food.
The client is taking water, coffee, softdrinks and juice as her main fluids
everyday. The client drinks 5 7 glasses of water everyday. At her
present condition, the patient has just started a clear to general liquid
diet. The patient only takes soup and sips of water post surgery.

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ELIMINATION PATTERN

Before hospitalization the client is having regular bowel

movement. She defecates regularly once a day. The client described it as
yellow in color and hard in consistency. The client also mentioned that
the client seldom experience diarrhea or constipation. According to the
client she urinates five to six times a day with only small amount of
volume every voiding period. The client stated that she does not
experience any difficulty in urination. During hospitalization the clients
bowel movement decreased to zero per day and the client increased
frequency of urination to seven times a day with small volume of urine.
During her hospitalization, the client is not experiencing any difficulty in
urination. The client stated Wala naman ako nararamdamang hirap sa
pag-ihi, pero hindi pa ako ulit nag-ccr simula noong maadmit (Bowel
movement).

ACTIVITY EXERCISE PATTERN

Before hospitalization, the client usually goes to the market to

buy food for the family. The client verbalized ang nagiging activity ko ay
yung pagaalaga ko sa anak ko, paglilinis ng bahay, pagluluto at
pamamalengke. The client does not experience any difficulty in doing
these activities because she enjoys doing those activities. The client
considers these activities as her primary type of exercise. The client
considers watching television and listening to radio as her leisure type of
activity. At her present condition, the client only stays on her bed and in
her room inside the hospital. Her only exercise is when she goes to the
bathroom to urinate. The client verbalized nahihirapan pa nga ako
gumalaw galaw dahil masakit yung inopera, kapag kaya ko yung sakit
ng sugat tsaka pa lang ako tumatayo para umihi. She also mentioned
that taking care of the drain limits her movement as she verbalized
natatakot ako na baka matanggal yung tubo, kapag gumagalaw ako.

SLEEP REST PATTERN

Before the hospitalization the client does not have any sleeping
rituals. The client is having six to eight hours of sleep everyday. She
usually starts sleeping from 10pm and wakes up at 5:30 am. The client
does not experience any difficulty or any disturbances in sleeping. The
client verbalized, maayos naman ang tulog ko, tuloy tuloy. At present
the client experiences disturbances in sleeping. She tends to wakeup
when she experiences pain in the postoperative wound. She is also
interrupted in sleeping whenever and when the nurse-on-duty is taking
her vital signs.

SENSORY SENSUAL PATTERN

Before hospitalization the client does not experience any eye and
ear problem. The client experienced abdominal pain prior her
hospitalization. She verbalized, sumasakit yung tiyan ko pag katapos ko

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COGNITIVE PATTERN

ROLE RELATIONSHIP PATTERN

VALUE BELIEF PATTERN

kumain. The client mentioned that nothing relieves the pain that leads
to their consultation. At her present condition, the abdominal pain was
eliminated. The client only experiences pain on her postoperative
wound, with a pain scale score of 6/10.
The client verbalized Sabi ni doc, uuwi din daw ako kaagad pero
hindi pa tatanggalin itong drain. Client M.V.R mentioned her concern
regarding the care of her postoperative wound and drain as she stated
Natatakot ako na baka matanggal yung drain kapag nagpalit ako ng gasa
sa bahay.
The client is married. The client mentioned that they get along
well in the family. She added that whenever there are problems in the
family they would try to resolve it by conversing over it.
The client is a part of the religion Iglesia ni Cristo. She mentioned
that she couldnt take foods made with blood and internal organs.

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LABORATORY AND DIAGNOSTIC RESULTS(Date Collected: 10/26/2014 3:07PM)

HEMATOLOGY
COMPONENT
RESULT
Red Blood Cell Count 4.24
(RBC)
Hematocrit (Hct)
0.37
Hemoglobin (Hgb)

NORMAL VALUES
Male: 4.5-6.0 x 1012 /L
Female: 4.0-5.5 x 1012 /L
Male: 0.40-0.54
Female: 0.37-0.47
Male: 120-170g/L
Female: 110-150 g/L
150-450 x 109/L
Adults: 5-10 x 109/L
Children: 6.2-17.0 x 109/L
0.50-0.70
0.20-0.40
0-0.07
0-0.05
0 Rh-D Positive

125

Platelet Count
380
White Blood Cell Count 6.4
(WBC)
Segmenters
6.4
Lymphocytes
0.68
Monocytes
0.27
Eosinophils
0.04
Blood Type
0.01

INTERPRETATION
Within Normal values
Within Normal Values
Within Normal Values
Within Normal Values
Within Normal Values
Within Normal Values
Within Normal Values
Within Normal Values
Within Normal Values

HEMOSTASIS
Clotting Time
Bleeding Time

RESULT
3 minutes
1
minute
seconds

NORMAL VALUES
2-5 minutes
30 2-7 minutes

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INTERPRETATION
Within normal values
Within normal values

ULTRASOUND RESULT
NAME:M.V.R.
AGE: 28 years old
SEX: Female
DATE: October 24, 2014
CASE NO: 14- 1768
EXAMINATION: Upper Abdomen
History: Epigastric pain radiating at the back

The liver is normal in size, exhibiting homogenous parenchymal echo pattern.

Intrahepatic ducts are not dilated. Common duct is within normal size. There is
an apparent intraluminal faintly shadowing echogenic structure within the
proximal portion of the common bile duct. Portal vein and its tributaries are
unremarkable.
The gallbladder is normal in size measuring about 2.90 cm in its widest
transverse diameter. There are multiple small intraluminal shadowing echogenic
structures within the gall bladder, the largest measures about 3.9mm in
diameter. The wall is not thickened.
The pancreas is within normal size with homogenous parenchymal echo pattern.
The pancreatic duct is not dilated No mass lesion seen.
Scanning the epigastric area shows prominent gastric wall.
The spleen is within normal size with homogenous echo pattern. There are no
masses noted. Splenic vessels are not dilated.
Both kidneys are within normal size with right measuring about 9.24cm x 4.02cm
x 3.64cm (LxWxAP) while the left measures approximately 9.96cm x 3.75cm x
2,99cm (LxWxAP). Parenchymal echopattern is homogenous. Neither echogenic
structure nor lesion seen. The pelvocalyces are not dilated.

IMPRESSION:
Probable choledocholithasis. Re-scanning is recommended
evaluation.
Cholecystolithiases
Prominent gastric wall. Findings may correlate with gastritis
Unremarkable pancreas, spleen and kidneys.

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for further

RADIOLOGY RESULT
NAME:M.V.R
AGE: 28 years old
SEX: Female
DATE: October 26, 2014
EXAMINATION: INTRA-OPERATIVE CHOLANGIOGRAM

There is satisfactory opacification of the common bile duct, main hepatic duct,
right and left intrahepatic biliary passages which are slightly dilated. There are
two rounded filling defects demonstrated in the middle portion of the common
bile duct.
There is reflux of contrast material into the duodenal loop.

IMPRESSION:

Findings suggestive of retained choledocholithiases.

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MEDICAL MANAGEMENT
(Upon Admission)
o Admit to room of choice under the service of Dr. Rey Ronquillo
o Secure consent for admission and management
o TPR every shift and record
o Nothing per orem temporarily
o Diagnostics: CBC, APC, Blood Typing, Clotting time and Bleeding Time, Urinalysis,
Chest x-ray PA
o Therapeutics: Cefazolin 1 gram an hour prior the surgery ANST
o IVF: D5LR 1L for 8 hours
o For Cholecystectomy common bile duct exploration, IOC, T-tube insertion on call
today
o Secure consent for the procedure
o Notify Operating Room
o Notify Dr. Martin Domingo for anesthesia
o Notify Dr. Robert Flores regarding assisting for the operation
o Refer accordingly
(Post-operative Orders)
o To Recovery Room
o Monitor vital signs every five minutes for 15minutes
o Nothing per orem
o Flat on bed for 8 hours
o Oxygen inhalation at 2-3LPM
o Continue D5LRS 1L for 8hours
o IVF to follow:
o D5LRS 1L for 8hours
o D5NM 1L for 8hours
o Medications: continue Cefazolin 1 gram every 8 hours intravenously
o Ketorolac 30mg every 8 hours intravenously ANST for 3doses
o Ranitidine 50mg every 8 hours while on NPO

SURGICAL MANAGEMENT

Cholecystectomy with common bile duct exploration, Intraoperative Cholangiogram

and T-tube insertion

Cholecystectomy is the surgical removal of the gallbladder. It is a common treatment of

symptomatic gallstones and other gallbladder conditions. Surgical options include the
standard procedure, called laparoscopic cholecystectomy, and an older more invasive
procedure, called open cholecystectomy.

20

Common bile duct exploration is done to consider the presence of bile stones in area.
This is also done to ensure that any formation of stones can be found and removed from
the area.
Intraoperative Cholangiography and Cholangiogram can be performed during an open
cholecystectomy to allow the surgeons to view the anatomy of the bile duct system. The
surgeons order this kind of procedure to verify if all formation of gallstones in the
system was removed. This procedure may also assure the surgeons that there was no
damage inflicted in the common bile duct before removing the gall bladder.
T- tube is being inserted into the bile duct to perform as a passageway for the dye to be
introduced to the patient. The t-tube also allows the bile to be drained while the duct is
in the process of healing post-operatively.

21