I. INTRODUCTION The Gallbladder is a small, pear- shaped organ in the abdomen. Its job is to store and release bile, a fluid made by the liver which helps break down fats in the food you eat. It also concentrates Bile by removing the water. But if stones form in the Gallbladder, they can block the release of bile and can cause pain and lead to serious complications like Cholecystitis. Cholecystitis is an inf lammat ion of the gal lbl adde r wal l and nearby abdomi nal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state ofstones or calculi within the gal lbladder lumen. Gallstones are cry stalline str uctures for med by concre tio n (harde ning) or accret ion (adher ence ofparticles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may under go a change in comp osition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation. So met imes, persons wi th ga ll bl adde r di sease have fe w or no sympto ms. Others, however, will eventuall y develo p one or mor e of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that pre vents the gal lbladder fro m emptyi ng (usual ly by obstructin g the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment. The only treatment that cures gallbladder disease is surgical removal of the gal lbladder, called cholec yst ect omy . Genera lly , when stones are pre sent and cau sing sympto ms, or whe n the gal lbl adde r is inf ect ed and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication. 1
scale of 0-10. She did not seek any medical consultation instead she takes
Mefenamic Acid to relieve pain.
In June 23, 2010 or 2 months Prior to Admission, the patient has
consultation in a private clinic. The patient was diagnosed of having
Gallbladder stones as evidenced by results of her abdominal ultrasound. Still,
she experiences right upper quadrant pain that still radiates to the back. The
patient was advised to undergo surgery but at first she refused due to
financial problems but later on she agreed to undergo operation since she
cannot tolerate anymore the pain. Hence, she was admitted at the Baguio
General Hospital and Medical Center for medical treatment and for removal
of Gallbladder stones.
IV. Past Medical History
In February 10, 2010, the patient had undergone Colonoscopy. The
patient stated that she underwent that procedure due to Irregular bowel
movement. The results of the procedure reveal a normal colon. She was thenadvised to increase her fiber intake. As for the patient’s OB history, she has
an OB score of G1P1 (1001). Her menstrual period started when she was 15
years old. She delivered her daughter via Caesarian Section in 2005 because
the presentation of her child was in complete breech. She also stated that
she uses Natural Family Planning Methods like Calendar Methods. She
doesn’t claim any allergies to any foods.
V. Family History
The patient claims that there is family history of hereditary diseases
such as Hypertension. Her father suffered from arthritis. She has an older
brother that is in Coma 2 months ago due to stroke. The patient also claims
that they had no history of Pulmonary Tuberculosis and Coronary Artery
Diseases.
VI. Social and Environmental History
The patient is a pawnshop worker. She interacts with other people by
conversing with other people. Most of the time at work, she sits on the chair
and seldom walks. Whenever she’s at home, her usual activities include
cleaning the house, doing the laundry, and cooking foods. She is fond of
reading newspapers and watching TV. The patient said that she always eats
vegetables and she also fond of eating salty and fatty foods. She also likes to
drink soft drinks such as coca cola most of the time and only drinks water
every time she feels the urge to drink. She is neither a smoker nor an
Patient ERD appears to be calm but weak during the assessment. She has initial
Vital signs of 38.3 degrees Celsius for her temperature taken at the axilla using
digital thermometer, 71 beats per minute for her pulse rate, 25 cycles per minute
for her respiratory rate, and 120/90 mmHg for her blood pressure. She has a
capillary refill of 1-2 seconds using blanch test.
She is about 5 feet 2 inches tall in height and about 120 pounds. She has a
brown complexion. She has a black and oily hair. Before her scheduled operation,she appears to be normal but anxious due to her upcoming surgery at the time of
the assessment and as manifested by an increase in RR which is 25 CPM and
verbalization of feelings regarding her upcoming procedure.
B. Head, Eyes, Ears, Nose, Throat (HEENT)
Head
During inspection, her head is symmetrical. There were no lesions and masses
noted. Hair evenly distributed. Scalp is has no dandruff or any other fungal
infections. There are no contusions or scars noted. Upon palpation, the skull size is
normocephalic and is round.
Eyes
Upon inspection, the eyebrows are symmetrically aligned. Eyelids are fair in
color; does not cover pupil or sclera and closes symmetrically. Her eyes blink
voluntarily and bilaterally. Her eyes are in line with each other and moves freely.
Conjunctiva is normal in color. No presence of lesions noted. Upon using penlight
and passing through her eyes, her pupils are brown in color, eyes are equal and
round, it is reactive to light and eyes have the ability to focus on objects that are
close and far. She can see different size of objects at different angle. She is able to
read even without the aid of eyeglasses and when looking straight ahead. She
doesn’t claim of blurring of vision. Also, she can see objects which are either big or
small. Eyes are firm and not tender upon palpations.
Ears
Upon inspection, the top of the ear is lined up with the outer corner of the eye.
Ears size and shape is symmetrical. Upon doing the voice whisper test, she can
distinguish the loud and soft voices. She is able to hear without the prosthetic
devices. She can clearly hear from a distance of six metes. There are no otherdischarges noted and the ears of the patient are clean. Upon palpation, no masses
and soreness in the pinna noted.
Nose
Upon inspection, nose is symmetrical, smooth and tan. Nasal mucosa is pale.
Nares are oval and symmetrical. She does not have any nasal discharges. Upon
palpation, no lesions and masses noted. She has also the ability to distinguish
odors. Both nares are patent.
Mouth and Throat
Upon inspection, we instructed the patient to open her mouth and no
inflammation of tonsils noted and has a pale of buccal mucosa with white patches.
The patient has dry and cracked lips. Teeth are with tartar and dental carries. When
we offer some food she is able to distinguish taste. She doesn’t have dysphagia and
she has odorous breath. When we asked the patient to open and close her mouth
she can voluntarily do it.
C. Respiratory System
During assessment the patient has a respiratory rate of 25 cycles per minute
which is higher to the normal range because she compensates to the pain that shefelt. Her Respiratory Rate has a deep regular rhythm. Cough and Cold are not
observed. She has clear breath sounds upon auscultation of the different lung fields.
The rise and fall of the abdomen is present during RR taking. The thorax is
symmetrical upon inspection. There are no depleted part and lesions noted.
D. Cardiovascular System
Upon inspection, there is no presence of peripheral cyanosis. Her capillary refill
returns after 1-2 seconds. Her nail beds are not cyanotic. Patients blood pressure is
120/90 mmHg which is taken when the patient is sitting. No cardiac arrhythmias
noted with Pulse rate ranges from 70-80 beats per minute as well as her Cardiac
rate. Her pulse is bounding and is regular in rhythm.
E. Gastrointestinal system or Abdomen
The patient eats 100% of the food served before the procedure was done and
drinks a lot of water. However, after the patient underwent the procedure, the
Doctor ordered clear liquid diet. Her abdomen is slightly distended and soft upon
palpation. Her abdominal girth measures 31 inches or 79cm upon assessment. Her
bowel sound is hypoactive upon auscultation on all quadrants of the abdomen. We
also noted a lower longitudinal midline incision scar as a result of her Caesarian
Section operation 5 years ago.
F. Genito-Urinary System
Before she had undergone the surgical procedure, the patient urinated 3 times
during the duration of our duty. Her urine is
yellow in color. No hematuria noted on her urine. The patient does not complain of
difficulty of urinating nor pain whenever she urinates. However, after she had
undergone the surgical procedure, the patient has an IFC and upon checking on her
urine bag, her urine measures 250cc.
G. Muskulo-skeletal System
Upon assessment, the patient has a minimal range of motion and needs
assistance in performing activities due to impaired physical mobility secondary to
the present condition. Upon inspection, the patient’s upper and lower extremities
are equal or symmetrical. Absence of lesions noted. She had a good grasp on both
hands which is scored as 4/5. No numbness noted on the lower extremities. She can
