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 inflammation of the gallbladder wall and nearby abdominal 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 of
stones or calculi within the gallbladder lumen. Gallstones are crystalline
structures formed by concretion (hardening) or accretion (adherence of
particles, accumulation) of normal or abnormal bile constituents. According
to various theories, there are four possible explanations for stone formation.
First, bile may undergo a change in composition. 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.

Sometimes, persons with gallbladder disease have few or no

symptoms. Others, however, will eventually develop one or more 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 prevents the gallbladder from emptying (usually by obstructing 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 gallbladder, called cholecystectomy. Generally, when stones are
present and causing symptoms, or when the gallbladder is infected 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.

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 IMAGES

Figure 1. Normal Anatomy of Gall bladder

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 Figure

2. difference between Normal and inflamed gall bladder.

Figure 3. Gallbladder with stones

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 Figure 4. Location of Gallstone formation

Patient’s Profile

Name: ERD

Address: Asan Norte, Sison, Pangasinan

Date of Birth: May 26, 1974

Sex: Female

Nationality: Filipino

Religion: Catholic

Date of Admission: August 4, 2010

Time of Admission: 1:15 pm

Admitted at: Baguio General Hospital and Medical Center

Admitting Physician: Dr. DD

Admitting Diagnosis: Calculous Cholecystitis

Final Diagnosis: Calculous Cholecystitis S/P Open Cholecystectomy

II. Chief Complaints

Right Quadrant pain for 7 days and fever

III. History of Present Illness

2 years prior to admission (PTA), the patient complains of On-and-Off

right upper quadrant pain but not related to trauma. Her abdomen is tender
upon direct palpation and pain was radiating on the back and rated as 7 on a

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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 then
advised 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
alcoholic beverage drinker.

VII. Physical Examination

A. General Survey

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 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 other
discharges 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

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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 she
felt. 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

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lift her both leg without minimal assistance. She can resist the force applied on her
leg which is scored as 4/5.

H. Integuumentary System

Upon inspection, the patient’s skin is generally brownish in color and pallor
on arms and soles. She has dry and cracked pale lips. She has no other wounds
present aside from the incision she had on her abdomen. Her black hair is
terminal in the scalp, eyelashes, eyebrows, and axilla. Fingernails and toenails
are properly trimmed and cleaned. Jaundice is not present on the patient. She
has a good skin turgor for about 1-2 seconds. She has a lower longitudinal
midline incision scar on her abdomen due to CS.

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