Intro Lab Results
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Transcript of Intro Lab Results
I. INTRODUCTION
Gallstones develop in the gallbladder from crystals of either cholesterol or
bilirubin. Stones can be too small to be seen with the eye or can range from the size of
grains of sand to the size of golf ball. There may be one or hundreds of stones in the
gallbladder. At any point, stones may obstruct the cystic duct which leads from the
bladder to the common bile duct and cause pain (biliarycolic) infection and inflammation
(cholecystitis) or both.
Stone in the gallbladder is the fifth leading cause of hospitalization among adults
and accounts for 90% of all gallbladder and duct disease, seventy to eighty percent of
patients’ gallstone remain asymptomatic throughout their lives. About 1-3 % of these
patients exhibit symptoms in any year. Risk of developing gallstones increases with
age. It afflicts 10-20% of adult population.
Incidence is more common in women, with female ratio approximately 2.4.
Women between the ages of 20 and 60 are twice likely to develop gallstones than men.
Women are at risk because estrogen stimulates the liver to remove more cholesterol
from blood and divert into bile.
Gallstones usually remain asymptomatic initially. They start developing
symptoms once the stones reach a certain size (>8mm).A main symptom of gallstones
is commonly referred to as a gallstone attack, in which a person will experience intense
pain in the upper abdominal region that steadily increases for approximately thirty
minutes to several hours. A victim may also encounter pain in the back, ordinarily
between the shoulder blades or pain under the right shoulder. In some cases, the pain
develops in the lower region of the stomach, nearer to the pelvis, but this is less
common. Nausea and vomiting may occur.
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The following objectives guided the researchers in this case study:
a.) Patient Centered
Our primary goal is to provide maximum patient care for the patient’s
recovery.
To impart health teaching to the patient and other members of the family
which may help them better understand the patient’s present condition.
b.) Nurse Centered
To identify the patient’s problem associated with the disease.
To gain more information about the disease and the proper management
for the patient suffering from this specific disease.
II. BIOGRAPHICAL DATA
Name : VILORIA, MELO JANE LARA
Birth Date : August 31,1971
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Age : 36 years old
Gender : Female
Civil Status Married
Address : San Pedro, Sta. Cruz, Ilocos Sur
Religious Affiliation : Roman Catholic
III. HISTORY OF PRESENT ILLNESS
According to the patient, she felt something painful at her upper right abdomen.
She was diagnosed at Candon Hospital and the results revealed that she has
gallbladder stones. The medicines prescribed were unrecalled. The persistence of the
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said condition made the family decide to seek consultation at Lorma Medical Center on
September 12, 2007 at 9:17 in the morning. The Admitting Medical Doctor, Dr. Emilio V.
Joven gave a clinical impression of Cholelithiasis. The patient is under the care of Dra.
Hildegunda Santos during her confinement at Lorma Medical Center for 6 days.
IV.PAST HEALTH HISTORY
According to patient MJV, she had never been hospitalized in the past but
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during her childhood, she suffered from chicken pox, measles, fever, cough and colds.
As a typical Ilocana, she eats whatever food on the table, but most of it were salty and
fatty foods like dried fish, pork and chicken barbecues.
She was fond of eating salty foods like dried fish and drinks less than 8 glass of
water per day. She consumed beverage drinks (coke 12oz) 3 bottles a day. She craved
and ate fatty foods for approximately two weeks. She spent her idle time watching TV
while eating salty foods.
Two years ago, patient MJV experienced abdominal pain at the upper right
quadrant accompanied by back pain categorized as cramping pain at the lumbar region.
Furthermore, throughout the year, she also experienced an abdominal pain (upper
quadrant) every after meal as well as severe back pain. She did not seek any medical
attention and no medication taken as well because as stated by the patient, taking a
rest would relieve the pain and she also though that the back pain was only due to
fatigue.
Two days prior to admission, again, she experienced severe back pains. Hence,
decided to seek for consultation at Lorma Medical Center under the care of Dr. Emilio V.
Joven (September 12, 2007). During the admission, patient MJV was experiencing an
on and off full pain. She was given an admission diagnosis of
Cholelithiasis/Cholecystitis and further she was confined. The following medications
were prescribed:Ketomed 30 mg IV every 6 hours, Nubain. She was scheduled for
Cholecystectomy on September 13, 2007 at 1:30 P.M
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V. FAMILY HISTORY
Father: Martin Lara
Illness: Cough
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Headache
Fever
Mother: Melicia Lara
Illness: Headache
Sister: Mary Jane Lara
Illness: Cough
Fever
Common colds
Headache
Grandfather: Bernardino Garcia
Age: 80 years old
Illness: Arthritis
VI. PERSONAL AND SOCIAL HISTORY
Patient MJV is a 36 year old woman who was born by normal delivery on August
31, 1971 at Candon Hospital, Candon, Ilocos Sur. Their house is a Bungalow type with
3 bedrooms and a comfort room located inside their house. Their house is located 250m
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away from the national road. She belongs to a nuclear type family. They disposed their
garbage by compost pit and burning. They get their water source from jetmatic pump
and use it for washing clothes, dishes and bathing purposes. They buy purified water for
drinking.
The patient admitted that she was fond of eating salty foods like dried fish and
drinks less than 8 glass of water per day. She consumed beverage drinks (coke 12oz) 3
bottles a day. She craved and ate fatty foods for approximately two weeks. She spent
her idle time watching TV while eating salty foods.
VII. REVIEW OF SYSTEMS/PHYSICAL ASSESSMENT
Patient: MJV Age: 36 years old
Sex: Female Race: Filipino
Date and Time of P.E: September 12, 2007; 10:00 A.M.
Pre-Operative Examination
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GENERAL APPEARANCE
Posture and Gait: slouched, bent posture and coordinated movement
Grooming and Hygiene: clean and neat
Body and Breath Odor: no body odor or minor body odor
MENTAL STATUS
Attitude: Cooperative
Mood: Appropriate to situation
Quantity/Quality and Organization of Speech: understandable and with coherence of
thought
I. INTEGUMENTARY
SKIN
- Color: Dark brown
- Uniformity of skin color: uniformed except palms and nail beds because
they have lighter pigmentation
- Appearance of skin: No pallor, no cyanosis
HAIR
- Growth over the scalp evenly distributed
- Color: black
- Hair thickness or thinness: hair is thick
- Hair infestation: no lice and dandruff
NAILS
- Shape: flattened angle
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- Nail bed color: light pink
II. HEAD
- Shape: rounded (normocephalic)
EYES
- Pupils are equally round and reactive to light
- Both eyes are coordinated and move in uniform with coordinated
alignment
EARS
- Color: same as facial skin
- Position: symmetrical
- Hearing acquity: good hearing acquity
NOSE
- Symmetric and straight
- Uniform in color
- No discharge or bleeding
- No tenderness
MOUTH
- Lips are slightly pink
- Has complete set of teeth, white in color
- Gums are light pink in color
III. NECK
- Neck Muscles: equal in size, the head is centered
- Temperature: warm to touch
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- Head movement: coordinated
IV. THORAX AND LUNGS
- Chest is symmetrical
- No tenderness, no masses
- Absence of crackles and murmurs
V. ABDOMEN
- Skin: unblemished and uniform in color
- Contour and Symmetry: Flabby
- Auscultation: normal, audible bowel sounds
- Palpation: Soft and no tenderness
VI. EXTREMITIES
- Upper and lower extremities: pulses are palpable, able to flex and extend
- Absence of edema
VII. GENITALIA
- Not examined
VII. RECTAL
- Not examined
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VIII. ANATOMY & PHYSIOLOGY
THE DIGESTIVE SYSTEM
The human digestive system is a complex series of organs and glands that
processes food. In order to use the food we eat, our body has to break the food down
into smaller molecules, and it also has to excrete waste.
Most of the digestive organs (like the stomach and the intestines) are tube-like
and contain the food as it makes its way through the body. The digestive system is
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essentially a long, twisting tube that runs from the mouth to the anus, plus few other
organs (like the liver and pancreas) that produce or store digestive enzymes.
THE DIGESTIVE PROCESS
The digestive process begins in the mouth. Food is partly broken down by the
process of chewing and by chemical action of salivary enzymes (these enzymes are
produced by the salivary glands and break down starches into smaller molecules).
After being chewed and swallowed, the food enters the esophagus. The
esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic,
wave-like muscle movements.
Then, food enters the stomach which is a large, sac-like organ that churns the
food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly
digested and mixed with stomach acids is called chyme.
After being in the stomach, food enters the jejunum, the duodenum and then the
ileum of the small intestine. In the small intestine, bile (produced in the liver and stored
in the bladder), pancreatic enzymes and other digestive enzymes produced by the inner
wall of the small intestine help in the break down of food.
After passing through the small intestine, food passes into the large intestines.
Here, some of the water and electrolytes are removed from the food. Many microbes
(like Bacteroides, Lactobacillus acidophilus, Escherichia coli and Klebsiella) in the large
intestines help in the digestion process. The first part of the large intestine is called
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cecum in which the appendix is connected, food then travels upward in the ascending
colon, then travels across the abdomen in the transverse colon to the descending colon
then to the sigmoid colon.
Solid waste is then stored in the rectum until excreted via the anus.
THE GALLBLADDER
The gallbladder is a pear-shaped sac about 7-10 cm (3-4 in.) long. It is located in
a depression on the posterior surface of the liver and usually hangs from the anterior
margin of the liver.
The functions of the gallbladder are to store and concentrate bile (up to tenfold)
until it is needed in the small intestine. In the concentration process, water and ions are
absorb by the mucosa of the gallbladder. When the level of cholecystokinin (CCK)
increases, the smooth muscle in the wall of the gallbladder contracts and forces bile into
the cystic duct and into the small intestine. When the small intestine is empty, a valve
around the hepatopancreatic ampulla (ampula of Vater) closes, and the backed-up bile
flows into the cystic duct to the gallbladder for storage
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IX. PATHOPHYSIOLOGY
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Dietary Influences(increased fat diet, inadequate fluid
intake)
Change in relative concentration of Bile components
Supersaturation of bile components(increased cholesterol, decreased bile salt and
lecithin)
Formation of stones in the Gallbladder
Accumulation of Bile
Obstruction of cystic duct by the stone
X. DIAGNOSTIC EXAMINATION
Candon Hospital
Name: Melo Jane Viloria Age: 36 Sex: F
X-RAY / ULTRASOUND REPORT
Liver and spleen are within normal size and configuration. Hepatic and splenic echoes are homogenous. The intrahepatic ducts and splenic vesselswithin normal caliber. Gallbladder is normal in caliber measuring 64 x 34
mm, with multiple rounded shadowing dense echoes. The walls are unthickened. Pancreas is not visualized due to overlying bowel gasses.
No free peritoneal fluid seen, within the Morrison's pouch. The kidneys are normal in position, size and contour. The central echo complexes are
intact with homogenous cortical echoes. There is a rounded shadowing high echolevel density in the midcortical region, right kidney, measuring 12mm.
Urinary bladder is sonographically intact. Unenlarged uterus with smooth contour and uniform mymetrial echoes.
IMPRESSION:>CHOLECYSTOLITHIASIS>Non-obstructing nephrolithiasis, right kidney
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Gastric Distention Compression of nerve endings
RUQ painVomiting
>Rest of the scanned organs are within normal. >Sonographic limits
Lorma Medical Center
Laboratory Department
CD1700 SPECIMENT DATA REPORT
Specimen ID #: 26 Analyzed: 09/12/07 Patient: VILORIA, MELO JANE
TEST RESULT REFERENCE RANGE (Limit 3)
WBC 10.0 K/uL 4.0 – 11.0 K/ulLYM 2.3 23.2%L 0.6 – 4.1 10.0 – 58.5%LMID 0.3 2.9%M 0.0 – 1.8 0.1 – 24.0%MGRAN 7.4 73.9 %G 2.0 – 7.8 37.0 – 92.05G
RBC 4.46 M/uL 3.60 – 6.00 M/uLHGB 12.1 g/dL 12.0 – 18.00 g/dLHCT 36.8 % 36.0 – 55.0%MCV 82.6 fL 80.0 – 100.0 fLMCH 27.1 pg 27.0 – 31.0 pgMCHC 32.9 g/dL 31.0 – 36.0 g/dLRDW 14.4 % 11.5 – 14.5%
PLT 243 K/uL 150 – 450 K/uL
BLOOD TYPE “A”
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Clotting Time = 3 minutes Bleeding Time = 2 minutes & 30 second
CLINICAL SIGNIFICANCE:
The result of patient MJV’s Blood Chemistry was within the parameters of normal range basing from the range provided by the agency (LMC).
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