I.

INTRODUCTION

They say that along with old age comes a different perspective
of health. As many of us know the older we get the more prone we are to
certain health problems and diseases. Such is the case of Mr.EDA

Cholelithiasis is the fifth leading cause of hospitalization among adults.

The disease may also be occurring in persons who are obese, who have high
cholesterol, or who are on cholesterol lowering drugs. In most cases,
gallbladder and bile duct diseases occur during middle age. Between ages 20
and 50, they're six times more common in women, but incidence in men and
women becomes equal after age 50. Incidence rises with each succeeding
decade. Diseases of the gallbladder and biliary tract are common and painful
conditions that may be life threatening and mostly require surgery. They are
generally associated with deposition of calculi and inflammation.

1
II. OBJECTIVES
GENERAL OBJECTIVE:
This study aims to enhance the knowledge and improve the critical
thinking and nursing skills in caring for a patient with Cholelithiasis from the
time of admission, Peri-operative care until discharge.

SPECIFIC OBJECTIVES:
• Present an informative case of a patient diagnosed with Cholelithiasis
• Know the actual history and determine the factors that lead to the
development of the disease.
• Provide a comprehensive clinical discussion of the disease process
• Identify the needs of the patient and prioritize the nursing problems
• Formulate Nursing Care Plans and evaluate the effectiveness of the
treatment and management

Significance of the Study

We undertook the present study to outline key aspects of the
presentation and management of this condition at this secondary hospital.
Through this case study, the researchers hope to benefit the following not
necessarily with the use of sophisticated and expensive technologies but
rather the use of effective strategies based on holistic approach. This study
provides a wide range of nursing interventions that can help the health care
team in managing cholelithiasis competently and successfully. This study
supplies additional information regarding a list of procedures and
management used that were proven to be effective in treating cholelithiasis.
This can also improve the quality of nursing care which may result to a
decreased incidence of mortality. This study is highly beneficial to the
following:
Patient and Significant others - that they may be oriented and have a
deeper understanding about Cholelithiasis. They will be more
cognizant of the ways in which to prevent further complications of the
disease on the patient and possibly on other members of the family

2
 Nurses – that they may further reinforce their existing knowledge, skills
and attitudes in the practice of their profession and that they may
continue to be pillars in health maintenance and disease prevention.
Other Health Care Providers – that they may maintain an excellent
and holistic approach to the care and management of Cholelithiasis,
encourage participation of all members of the health team in achieving
a speedy resolution and immediate disposition of these cases so as to
avoid further spread of infection
Nursing Education and Training - that this case study may be a
valuable addition to its pool of references and information pertaining to
Cholelithiasis and the conduct of case studies in general

Scope and Limitation of the Study

The study deals with a case of Cholelithiasis of a patient admitted at
the Military Ward of Camp Lapulapu Station Hospital. It presents a
comprehensive discussion of Cholelithiasis and the correlations of each
complication.
Available data and information are gathered from various researches;
different outside sources are used vis-à-vis hospital records. Actual
observations, assessment and valuable input from the patient were utilized as
basis of interventions for the patient.
Nursing care management focused on priority health problems
identified throughout the patient’s hospitalization at CLSH beginning 17 July
2010 to 12 August 2010 and re-admitted on 17 August 2010 to 14 September
2010. The present status of the patient reflects actual interventions done
within the said period. Patient was closely monitored to prevent deterioration
alleviate suffering.
The patient had his operation at Chong Hua Hospital and was admitted
there 2 days pre-op and 2 days post-op thus limiting our study to what we had
only handled. Only 4 of our groupmates were able to render care to our
patient.

3
Reason for Choosing the Case
Cholelithiasis and Laparoscopic Cholecystectomy is definitely not a
rare. In line with this, we decided to take the opportunity to make a case study
on the said topic not only to gain further knowledge on the said disease and
surgical procedure but also to learn more about the medical, surgical
management and the nursing care given to such patients. The hopes are that
this paper would also be able to guide us nurses on the care rendered should
they encounter such client.
DATABASE
A. Patient’s Profile
Name: Mr. EDA
Age: 54 years old
Sex: Male
Marital Status: Married
Educational Attainment: Vocational
Religion: Roman Catholic
Place of Birth: Poblacion Minglanilla Cebu
Nationality: Filipino
Address: 752 Upper Calajoan, Minglanilla, Cebu
Name of Hospital: Camp Lapulapu Station Hospital
Date of Admission: 17 July 2010 and 17 August 2010
Ward: Military Ward
Admitting Diagnosis: 1.Essential Hypertension Stage II-Uncontrolled
2. Diabetes Mellitus Type II
3. Cholelithiasis (non-obstructing)
Admitting Physician: Captain Louise A. Cajita

Socio-demographic Characteristics
Patient EDA lives in a household of six in a family-owned bungalow
type of house. Living with my wife, two sons and one daughter and one
granddaughter. It has three bedrooms and one restroom. He is an active
Master Sergeant of Philippine Air Force of PAF, AFP assigned in Mactan
Benito Ebuen Airbase in Lapulapu City but he is residing at Upper 752 Upper
Calajoan Minglanilla, Cebu. His wife is a plain housewife. The patient has

4
three children. His eldest child is 27 years old living with them; he is working
as a seaman in an international cruise ship. Her daughter next to the eldest is
22 years old. She has no work and is not studying with one daughter she is a
single parent. His youngest is 16 years old studying at San Carlos University
as a Fourth year high school. The family also owns 500 square meters
inherited lot. The family has no business and no other source of income rather
than Msgt. EDA salary and his eldest son salary.

Concept of Health, Illness and Hospitalization

The mother claimed that patient X does not get sick easily and
experience illness seldom. This is his first hospitalization for this kind of
illness. Patient is aware that he is in the hospital to be treated for his
condition. Patient also verbalized his feeling about the hospitalization as
exciting and the same time nervous and scary. The parents are worried about
the patient’s condition of the procedures and scared about the procedures to
be undergone by the patient.
Common Health Practices at Home
Whenever the patient gets cough or flu he would usually take over the
counter medications. He is a trained flight crew knowledgeable on 1st aid
treatment. He usually has a medicine kit in the house and always checks
every now and then what needs to be filled in. If the patient does not get well
in 3 days, she then consults a doctor. The family does believe in herbal
remedies and organic medicines to be incorporated with boiling water, such
as guava leaves for example. Patient X has completed the three doses of
Diptheria, Pertussis, Tetanus (DPT), Oral Polio Vaccine (OPV) and Hepatitis
B vaccine. He also had his BCG and her Anti-Measles. All were given in a
local health center.

Immediate factor that brought about illness

He was experiencing discomforts at his right upper quadrant of his
abdomen and sudden high grade fever which made him sought consult and
was advised to have ultrasound of the whole abdomen. Gallstones were
found that prompted the patient’s admission at this institution and surgical
operation at Chong Hua Hospital for a Laparoscopic Cholecystectomy.

5
B. Comprehensive History
1. History of Present Illness

12 years prior to admission patient complained of persistent

polyuria, polydipsia and polyphagia. Consult with a diabetologist was
done. Laboratories taken. Patient was diagnosed to be Hypertensive.
Unrecalled medications given. 5 years prior to admission Metformin
500 mg/tab 1 tab BID po was prescribed plus an unrecalled medication
which were taken with good compliance. FBS ranged from 100-120
mg/dl. 15 days prior to admission patient consult was sought. FBS=166
mg/dl. SC insulin injections were prescribed-28 IU. Few hours prior to
admission consult with diabetologist done. SC insulin injections were
increased to 25 IU in AM + 10 IU in PM.

1 year prior to admission patient was diagnosed to be

Hypertensive. BP=120/80-130/80. Usual highest BP=160/100.

3 months prior to admission patient was diagnosed to have

Cholelithiasis based on an Ultrasound taken after suspicious findings
were noted on Chest X-ray. Patient claims to be asymptomatic. No
History of jaundice and right upper quadrant pain.

2. Past Medical History

Patient EDA had no history of childhood illnesses. According to

his parents, the patient has no allergies to any foods or drug
medications.

PRENATAL:
Cognizant of pregnancy at 1 month AOG, due to missed mens
confirmed by a positive pregnancy test at home, with regular PNCU at
Chinese General Hospital with regular intake of multivitamins and
ferrous sulfate. No other maternal illness noted; No exposure to
radiation or teratogenic drugs.

NATAL:

6
 Born to a 31 year old G2P2 (2002) via NSD at Bulingit General
Hospital with good cry and good activity. Discharge as well baby after 8
days.

NUTRITIONAL HISTORY:
Patient D.L was purely breastfed for 6 months. Semisolid foods
were introduced when he was 7 months old.
Birth – 6mos – Bona
6mos - 1 y/o – Bonamil
1 y/o – 1 6/12 – Lactum
1 6/12 – 3 y/o – Nido Jr
Present – Nido
 Table food – self feeding, uses fork and spoon
 no allergies to foods and drugs
 Vitamins: ceelin and clusivol

IMMUNIZATION:
 BCG
 DPT1, DPT2, DPT3
 OPV1, OPV2, OPV3
 HBV1, HBV2, HBV3
 MEASLES
- @ local health center

7
 3. Family and Social History

Legend:

Grand father Grand father Father Patient

Father Side Mother Side

Grand Mother Grand Mother Mother

Father Side Mother Side

(+) Hypertension (+) Hypertension (+) Heart Disease (+)Diabetes Mellitus

Complication (+) Hypertension

(+) Hypertension (+) Hypertension

(+) Hypertension
(+) Diabetes Mellitus
(+) Cholelithiasis

8
 Social History
The patient lives with his parents and one sibling. They own a
bungalow type house with three bedrooms, 1comfort room. Well
lighted, and well ventilated. Drinking water is purified, and garbage is
collected regularly by the local garbage collector of the barangay.

He is a Roman Catholic and they attend the mass every

Sunday. Before he is always attending mass in Mactan airbase chapel
were they are celebrating mass every Sunday. But now since he is
staying in Minglanilla, he is attending mass in Minglanilla parish church.
The patient loves to spend his time with his older brother who is living
near him in the next town of Naga.

FUNCTIONAL ASSESSMENT

I. Health Perception/ Health Management Pattern

He believes that not all time if you are sick, it needs to be seen by a
doctor. He himself is a trained in flight crew procedures in dealing
with primary care interventions as trained in first aid in the military.
He is also prepared with his medication kit in there house in case of
emergency.

II. Self Esteem/ Self Concept/ Self Perception Pattern

His concept in dealing with everyday stress is everyday he drinks

one bottle of rhum or gin and smokes one pack of cigarette a day.
But now he change already his coping actions with daily exercise.
He does not smoke or drink alcoholic beverages but only drinks
coffee.

III. Social Pattern

At the age of thirty five he was married on January 1991 in Mactan

Air Base Chapel on a mass weeding. He Drinks one bottle of rhum
or gin every day but drinks four to five bottles of beer on occasions,

9
 he smokes one pack of cigarette every day particularly menthol
cigarette.

IV. Socio-Economic Pattern

At present, he resides at 752 Upper Calajoan Minglanilla, Cebu

together with his family. His wife is a plain housewife with no work
and no business. The only income they have is his salary and the
salary of his eldest son.

V. Nutrition-Metabolic Pattern

Before his admission in the hospital with role out diagnosis of

Cholelithiasis he loves eating meat dishes specially pork at dinner.
He also takes his morning snacks with two pieces of biscuits with a
hot coffee the same with his afternoon snacks. Now he eats fish
and vegetables very often and avoids meat dishes very often. He
still have his morning and afternoon snacks with biscuits and
decaffeinated coffee.

VI. Activity-Exercise Pattern

Before he stays in the Air Force barracks and every four o’clock in
the early morning almost every day he jogs. Now he is only doing
brisk walking in the morning or in the afternoon. But every other
day.

VII. Sleep-Rest Pattern

Before he usually sleeps at ten o’clock at night after his work in the
airbase and wake up at three o’clock in the early dawn. Now he
sleeps at eight in the evening after watching the television news
and still he wakes up at three in the morning and makes some little
stretching and drinking some coffee.

VIII. Elimination Pattern

During night time he wakes up between one or two o’clock in the

dawn to urinate and he eliminates his bowel at five o’clock in the

10
 morning after taking a bath. But if they have an early flight he
eliminates his bowel at seven o’clock in the morning already after
their flight when they arrive in the next station.

IX. Sexuality Reproductive Pattern

Tagae ko idea ani kay confidential man ni’

X. Interpersonal Relationship Resources

He had a close relationship with his family and relatives. He

observes a typical Filipino close family ties that they are very close
with each other and avoids any arguments or misconception with
his family relatives and even his friends.

XI. Values-Belief Pattern

He is a Roman Catholic by religion and observes mass every

Sunday. Sometimes he observes mass in Mactan Air Base Chapel
or in Mingalanilla Parish Church, it depends where he is at.

11
C. Physical Assessment

Date of Assessment: 17 July 2010 (Pre-Op)

I. GENERAL APPEARANCE
54 years old, male, conscious, coherent, calm, good oral and body hygiene,
stands 5 feet and 4 inches tall and weighs 68 kg, appropriate affect with
complaint of fever and epigastric pain.
The vital signs are as follows:
Temperature : 39.4 °C
Pulse Rate : 110 bpm
Respiratory Rate: 20 cpm
Blood Pressure: 150/100 mmHg

II. SKIN, HAIR AND NAILS

The patient’s skin is even, dry, warm to touch, and in good skin turgor.
There’s no noticeable skin irritation, edema, lump, abrasion, pallor and
cyanosis noted. The patient has a dark-complexion. Nail is clean, thick,
smooth, well rounded, capillary refill of less than 2 seconds, with a nail bed
angle of less than 160 degrees. There’s no inflammation and lesions noted.

III. HEAD AND NECK

The shape of the head of the patient is uneven with some lesions and scars.
No palpable lymph nodes, neck pain, stiffness, and enlargement of thyroid
gland noted.

IV. EYES
Clear with no secretions present. There’s also a corneal ulceration and eye
irritation noted with 20/30 vision, pupils are equally round and reactive to light
and accommodation. Eye brows are symmetrical, evenly distributed, thin and
black in color.

V. EARS, NOSE AND THROAT

12
Ears are symmetrical, medium-sized, brown in color, smooth and clean.
Nose is smooth and symmetric. Nasal mucosa is smooth, moist and pinkish.
Nares are patent. Septum is in midline position. No inflammation, pain,
discharge, bleeding, deviation and lesions noted.
Lips have some fissure due to dryness. For his mouth assessment, client has
moist oral mucosa, without lesions and unpleasant mouth odor. His teeth are
well-aligned, yellowish white in color, tartar and cavities are present in teeth
numbers 9 and 14.

VI. RESPIRATORY
For thorax assessment, there were no adventitious sounds noted. RR = 20
breaths per minute, symmetrical chest expansion, clear breath sounds.

VII. CARDIOVASCULAR
For his cardiovascular examination, there were no noted murmurs upon
auscultation of heart sounds at 110 beats per minute. No dysrhythmia, thrills
noted.

VIII. GASTROINTESTINAL
The abdomen has no striae, cuts or any lesions upon assessment. It is
rounded, soft, flabby, normoactive bowel sounds. Pain noted on the epigastric
area upon deep palpation. No rectal pain, scratch, lesion, bruise, wound, and
bleeding noted.

IX. NEUROLOGICAL
Cranial Nerve
Cranial Nerve Normal Findings Deviation
I – Olfactory -able to identify familiar odor with eyes closed
II – Optic -(+)sensory component of visual reflexes such as
the pupillary light reflex or accommodation of the
lens
III – Oculomotor - Normal dropping
IV – Trochlear -(+)ability to move eye laterally
VI - Abducens - Pupils are round, equal in size (about 2-3 mm in
diameter), and in the center of the eye

13
 -(4+) pupillary constriction
- Eye movement occur smoothly and precisely
- no nystagmus on elevation or depression of the
eyes

V - Trigeminal Motor: (+) ability to chew and strength to bite

Nerve Sensory: (+) ability to distinguish light touch and
pain in the ophthalmic branch, maxillary branch,
and mandibular branch
VII - Facial Nerve -Able to move his cheeks
-Able to smile
-Able to show his teeth
VIII - (+) ability to hear spoken words
Vestibulocochlear
IX - Motor:
Glossopharyngeal -Can move tongue from side to side and up and
down.
(+) gag reflex
Sensory:
-Can identify flavor applied to posterior tongue
X - Vagus (+) ability to swallow
(-) hoarseness of speech
XI - Spinal - can turn the head to the opposite side
Accessory - can elevate the shoulder on the same side
XII - Hypoglossal (+) ability to push the tongue to the side of the
mouth against resistance applied to the cheek.
(-) deviation, asymmetry, tremors, and
fascilutations

X. Sensory Function
Sensations are equal on both upper and lower extremities.

XI. Reflexes
Symmetrical normal reflex (+2) on both upper and lower extremities. (-)
Babinski reflex noted.

14
 MOTOR SENSORY

R L R
L
5/5 5/5 100%
100 %
5/5 5/5 100 % 100 %

XII. MUSCULOSKELETAL
His muscle tone is normal, ROM and his muscle strength is 5/5 in both upper
and lower extremities, including head and neck. Normoreflex are noted in left
and right biceps, triceps and patellar area. His functional level classification is
0 which means that he is completely independent. He has good posture and
can maintain his balance.

POST OP
17 August 2010
With vital signs as follows:

Temperature: 36.7°C
Pulse Rate: 80 bpm
Respiratory Rate: 20 cpm
Blood Pressure: 150/90 mmHg
Abdomen:
Have four (4) small post op incision sites present at the epigastric region,
umbilical region, right lumbar region and right iliac region, with non
soaked, non bloody Operative site dressing in place on each wound site. Pain
is also noted on the site with 5 as his pain score with a scale of 10 as the
highest and 1 as less pain. Abdomen is rounded, soft and flabby with
normoactive bowel sounds. No bleeding noted.
D. COURSE IN THE WARD

15
DOCTOR’S ORDER • Admitted to Military Ward
17 July 2010 1620H • Low salt, low fat, low cholesterol, diabetic diet (2.380
(admission) kcal/day). Divided into (298g CHO, 120 g CHON, 79 g Fat)
• ECG 12 leads, CBC, U/A, Blood Chemistry, HGT stat
• I & O every shift
• Monitor v/s every 2 hours.
• Medications:
o Paracetamol 150mg/ml 2 ml IVTT now
o Paracetamol 500 mg/tab 1 tab q 4 hrs po for T: >
37.5°C.
o Hyoscine-n-butylbromide 10mg/tan 1 tab q 6hrs po
o Metoprolol tartate 50 mg/tab 1 tab 2x/day po
o ASA 80 mg/tab 1 tab OD pc breakfast
o Metformin 500mg/tab 1 tab BID pc breakfast & dinner
po
o Acarbose 50 mg/tab 1 tab TID after 1st bite of meal.
• Start Venoclysis with PNSS 1 liter @ 30 gtts/min.
• TSB for T: > 37.5°C.
• For referral to LTC Larin for further management.
2100H • U/A result in and referred to PGI Yap with new orders made.
o Ciprofloxacin 500 mg/tab 1 tab BID x 1 week.
o Repeat U/A after 1 week.
o Monitor v/s q 4 hrs. (waking hours only)
o IVFTF with PNSS 1 liter @ 30 gtts/min.
18 July 2010 • Vital signs every 4 hours and record please
DAY 2 • IVFTF PNSS 1 liter @ 30 gtts/min.
• Increase Metformin to 500 mg/tab 1 tab TID po after main
meals.
• Shift Metoprolol to Captopril 25mg/tab 1 tab BID po
• Hold hyoscine-n-butylbromide & Acarbose
• For Fundoscopy
• For Chest Xray PA view
• IVFTF PLR 1 liter @ 10-15 gtts/min.
• Vital signs taken and recorded.
• Due medications given as ordered.
• I & O q shift monitored and recorded.
• Monitored for16any signs of unusualities.
19 July 2010 • IVFTF PL 1 liter @ KVO
• Vital signs taken and recorded
 Doctors Order
17 August 2010 (admission) • Admitted to Military Ward
0835H • Low salt, low fat, low cholesterol, diabetic diet
2,380 kcal/day (Divided into 298 g CHO, 119 g
CHON, 79 g Fat)
• CBC, U/A, FBS, BUA, Creatinine, Total
Cholesterol, Triglyceride was requested.
• Monitor v/s q 4 hours waking hours only.
• Medications:
o Cefuroxime 500mg/tab 1 tab BID po pc
breakfast and pc supper x 5 more days.
o Paracetamol + Tramadol (Dolcet) tab 1
tab po TID pc breakfast, lunch & supper x
2 more days.
o Amlodipine (Norvasc) 5mg/tab 1 tab po
pc breakfast.
o Glimeperide (Solosa) 2 mg/tab 1 tab po
OD pc lunch.
o Gemfibrozil 600mg/cap 1 cap OD po 30
mins before breakfast.
• For repeat SGPT after 2 weeks 8/31/10
• For follow up with Dr. Gacayan @ CHH OPD
8/20/10.
• For follow-up with Dr. Ikeda @ CHH OPD on
8/31/10 with SGPT result.
• Old chart retrieve at A & D section and attach to
chart.

1045H • Please revise Gemfibrozil 600mg/cap 1 cap po

every other day.
• May use amlodipine (Sedipin) instead of
Norvasc
• May use Glimeperide (Norizec) instead of
Solosa.

17
 1405H • Multivitamins cap 1 cap OD po pc breakfast
18 August 2010 • FBS taken
• Vital signs taken and recorded.
DAY 2 • Due medications given as ordered.
• Monitored for any signs of unusualities.
1930H
• Continue medications.
19 August 2010 • Vital signs taken and recorded.
• Due medications given as ordered.
DAY 3 • Monitored for any signs of unusualities.
1410H • FBS result in and referred to Major Cruz with
new order made.
o Simvastatin 20mg/tab 1 tab OD po every
H.S.
• Trip ticket made and forwarded to admin office.
20 August 2010 • Follow-up check up with Dr. Ikeda at CHH-OPD
0800H accompanied by NOD and SO via ambulance
no new orders made.
• Vital signs taken and recorded.
DAY 4 • Due medications given as ordered.
• Monitored for any signs of unusualities.
1300H
• Patient came in from CHH accompanied by
NOD and SO via ambulance.

21 August 2010 to • No new orders made.

22 August 2010 • Vital signs taken and recorded.
• Due medications given as ordered.
DAY 5 AND DAY 6
• Monitored for any signs of unusualities.
23 August 2010 • Vital signs taken and recorded.
• Due medications given as ordered.
DAY 7 • Monitored for any signs of unusualities.
1615H • For referral to the dental section tomorrow 24
August 2010 @ 0800H for evaluation.
24 August 2010 • Referred to Dental Section accompanied by RN-
Resident with advised to come back 01

18
 September 2010 because available dentist is at
DAY 8 the arriving honor.
• Vital signs taken and recorded.
• Due medications given as ordered.
• Monitored for any signs of unusualities.
1520H • For FBS 26 August 2010
25 August 2010 0820H • For Serum Creatinine determination and Total
Cholesterol and Triglyceride tomorrow 26
DAY 9 August 2010.
• Vital signs taken and recorded.
• Due medications given as ordered.
• Monitored for any signs of unusualities.
26 August 2010 • Serum Creatinine determination and Total
DAY 10 Cholesterol and Triglyceride taken.
• Vital signs taken and recorded.
• Due medications given as ordered.
• Monitored for any signs of unusualities.
27 August 2010 • Vital signs taken and recorded.
• Due medications given as ordered.
DAY 11 • Monitored for any signs of unusualities
1800H
• Serum Creatinine determination and Total
Cholesterol and Triglyceride result in and
referred to Major Cruz with new orders made.
o D/C Simvastatin
28 August 2010 to • No new orders made.
30 August 2010 • Vital signs taken and recorded.
• Due medications given as ordered.
DAY 12-DAY 14
• Monitored for any signs of unusualities.
31 August 2010 0800H • Follow-up check up with Dr. Gacayan at CHH
OPD accompanied by NOD and wife via
DAY 15 ambulance.
• Vital signs taken and recorded.
• Due medications given as ordered.

19
 1315H • Monitored for any signs of unusualities.
• Patient came in from CHH accompanied by
NOD and wife via ambulance with chart.
1330H • Referred to Major Cruz Dr. Gacayan’s order
written at the patients chart
• Please carry out doctors orders from CHH.
o Metformin 500 mg/tab 1 tab BID po pc
breakfast and pc dinner.
o Repeat Creatinine & SGPT on 28
September 2010.
01 September 2010 0900H • Patient referred to dental section accompanied
by RN resident and evaluated
DAY 16 o Periodentalasia (pdol on tooth # 15 and
9). Tooth # 9 for extraction tomorrow 02
September 2010 0900H
• Patient came in from dental section.
• Vital signs taken and recorded.
1000H
• Due medications given as ordered.
• Monitored for any signs of unusualities
02 September 2010 • Tooth extracted # 9
DAY 17 • Patient is advice to return 06 September for
follow up extractions tooth # 14.
• Vital signs taken and recorded.
• Due medications given as ordered.
• Monitored for any signs of unusualities
03 September 2010 to • No new orders made.
05 September 2010 • Vital signs taken and recorded.
DAY 18- DAY 20 • Due medications given as ordered.
• Monitored for any signs of unusualities.
06 September 2010 1000H • Tooth # 14 extracted
• Oral prophylaxis.
Day 21 • Vital signs taken and recorded.
• Due medications given as ordered.

20
 • Monitored for any signs of unusualities.
07 September 2010 to • No new orders made.
13 September 2010 • Vital signs taken and recorded.
DAY 22-DAY 28 • Due medications given as ordered.
• Monitored for any signs of unusualities.
14 September 2010 • Vital signs taken and recorded.
• Due medications given as ordered.
DAY 29 • Monitored for any signs of unusualities.
• EDRD Effective tomorrow 15 September 2010.
• Physical Profile (P2T).
• Final Diagnosis
o Cholelithiasis S/P Laparoscopic
Cholecystectomy
o Essential HPN Stage II-Controlled
o DM Type II-Controlled
• Provided patient with discharge clearance and
patient satisfaction survey.
15 September 2010 • Patient’s clearance are cleared and handled
over to the nurse on duty.
DAY 30 • Vital signs taken and recorded.
• Due medications given as ordered.
• Monitored for any signs of unusualities
1000H
• Drop patient at census at.
1515H
• Patient went home well @

CLINICAL DISCUSSION

Anatomy and Physiology

The gallbladder is a small pear-shaped organ that stores and
concentrates bile. The gallbladder is connected to the liver by the

21
 hepatic duct. It is approximately 3 to 4 inches (7.6 to 10.2 cm) long and
about 1 inch (2.5 cm) wide.

The function of the gallbladder is to store bile and concentrate. Bile is a

digestive liquid continually secreted by the liver. The bile emulsifies fats
and neutralizes acids in partly digested food. A muscular valve in the
common bile duct opens, and the bile flows from the gallbladder into
the cystic duct, along the common bile duct, and into the duodenum
(part of the small intestine).

Theoretical Schematic Diagram Precipitating Factor:

• Age (20-50)
Predisposing Factor: • Gender (Females are more
• Obesity/ Overweight prone)
• High Cholestrol level • Genetics
• High Calorie Diet • Diabetes
• Pregnancy/ Contraception

22
 Decreased bile acid synthesis Increased levels of fat in the blood stream

Increased cholesterol synthesis

Bile supersaturated with cholesterol

Stone formation

Pressure Obstruction

Bile Stasis

Decrease Fat Decreased Bile Increased Infection

Emulsification flow into the Inflammation Bilirubin
colon
 Cholecystitis
 Jaundice
 Far  Pancreatitis
 Pain (RUQ)  Pruritus
intolerance  Alcoholic  Fever  Tea-
 Anorexia Stool colored
 Nausea and  Leukocytosis
 Decreased urine
Vomiting Vit. K
 Weight absorption
loss
 Gaseous
eructation Surgical Management: Nursing Management:
 Flatulence • Open Cholecystectomy • Encourage ambulation
 Steatorrhea • Laparoscopic • Encourage deep breathing
Cholecystectomy exercises and use of
• Lithotripsy incentive spirometry
Medical Management: • Monitor intake and output
• Medications:
Actual Schematic Diagram • Monitor vital signs
- Antibiotics • Give patient health
- Analgesics Precipitating Factor:
Predisposing Factor: teaching for home care.
• Age (20-50)
• Obesity/ Overweight • Diabetes
• High Cholesterol level
• High Calorie Diet

23
 Decreased bile acid synthesis Increased levels of fat in the blood stream

Increased cholesterol synthesis

Bile supersaturated with cholesterol

Stone formation

Bile Stasis

Decrease Fat Increased

Emulsification Inflammation Bilirubin

 Jaundice
 Fat
 Pain (RUQ)  Tea-
intolerance??
 Fever colored
 Anorexia?? urine
 Nausea and
Vomiting??
 Weight loss??
 Gaseous
eructation??
 Flatulence?? Surgical Management: Nursing Management:
 Steatorrhea?? • Laparoscopic • Encourage ambulation
Cholecystectomy • Encourage deep breathing
Medical Management: exercises
• Medications: • Monitor intake and output
- Antibiotics • Monitor vital signs
- Analgesics • Give patient health
teaching for home care.

IV. MEDICAL MANAGEMENT

A. Laboratory/Diagnostic Procedure

24
In this section, we will discuss the diagnostic examinations done on the
patient and their significance towards the patient’s progress while admitted in
the hospital.
Apart from helping diagnose existing medical conditions in a patient, initial
tests done upon admission also provide us baseline data and information
regarding a patient’s health status.
Normal (reference) values used in the laboratory exams for this patient were
those of an adult male. Where applicable, reference values for pediatric
patients are included in the discussion of lab results.

Complete Blood Chemistry (CBC)

The Complete Blood Chemistry or CBC is a set of tests that examines
different components of the blood to check for such disorders as anemia,
infection, and many other diseases. This broad screening exam includes the
following:

Hemoglobin measures the amount of oxygen-carrying protein in the blood.

Low levels of hemoglobin usually indicate anemia while high levels result in
polycythemia, a blood disorder where RBC and hemoglobin production is
increased.
Normal range of hemoglobin in an old male is 14.0-18.0 10 6/uL. Figure 1
shows us that he is slightly anemic, with hemoglobin levels falling below the
acceptable range in 3 out of the 4 tests..

Hemoglobin Level-Male
(NV=14.0-18.0 g/dl)

14.5
14.3
14 13.9 13.8
13.5
g/dl
13 13
12.5
12
17-Jul 5-Aug 13-Aug 17-Aug
Hematocrit measures the percentage D
ofates
red blood cells in a given volume of
whole blood. Together with hemoglobin, increased hematocrit levels are
observed in diseases as polycythemia while decreases are seen with anemia.

25
Red blood cell count (RBC) is a count of the actual number of red blood cells
per volume of blood. Both increases and decreases can point to abnormal
conditions (e.g., polycythemia or anemia).
The following graphs for both hematocrit and RBC count of this patient mirrors
that of hemoglobin.

Hematocrit Level-Male (NV=42.0-52.0%)

44
43 43
42 42.3 42
41
%

40
39 39
38
37
17-Jul 5-Aug 13-Aug 17-Aug
Dates

Red Blood Cell (RBC) Count

12
(NV=4.7-6.1 x 10 /L)
4.9
4.8 4.78
4.7
4.6
x 10 12 /L 4.5 4.5 4.49
4.4
4.3 4.3
4.2
4.1
4
17-Jul 5-Aug 13-Aug 17-Aug
Dates

White blood cell (WBC) count is a count of the actual number of white blood
cells per volume of blood. An increase in WBC count signifies infection while a
decrease may indicate leukemia or a decreased ability of the immune system
to fight infection.
The patient’s WBC was all within normal limits with all the 4 test taken.

26
 White Blood Cell (WBC) Count
9
(NV=4.8-10 /L)

13
12 12.1
11
10
9
9
x 10 /L 8
7
6 6.1 5.8 5.55
5
4
3
17-Jul 5-Aug 13-Aug 17-Aug
Dates

White blood cell differential or Differential count looks at the types of white
blood cells present. There are five different types of white blood cells, each
with its own function in protecting us from infection. The differential classifies
a person's white blood cells into each type: neutrophils (also known as
segmenters or granulocytes), lymphocytes, monocytes, eosinophils, and
basophils.

An increase in neutrophils or segmenters indicates infection, as these are the

body’s first line of defense against foreign organisms. The same can be said
when lymphocytes are elevated. Increased eosinophils indicate an allergic
reaction.

27
 Differential Count
Eosinophils
1.8
1.6 Lymphocytes
0.72
1.4 Segmenters
0.38
1.2 n/a 0.33
1 0.1
0.38 0.4 0.01
0.8
0.9 0.66
0.6 0.53
0.4 0.47
0.2
0
17- 24- 31- 7- 14-
Jul Jul Jul Aug Aug
Dates

The platelet count is the number of platelets in a given volume of blood. Both
increases and decreases can point to abnormal conditions of excess bleeding
or clotting and can also be associated with diseases of the bone marrow such
as leukemia.

3
Platelet Count (NV=130-400x10 /L)

290
285
280
275
270
3
x10 /L
260
256
250

240
17-Jul 13-Aug 17-Aug
Dates

Mean corpuscular volume (MCV) is a measurement of the average size of

RBCs. The MCV is elevated when RBCs are larger than normal (macrocytic),
as in Pernicious anemia (due to vitamin B12 deficiency). When the MCV is
decreased, RBCs are smaller than normal (microcytic), as is seen in iron
deficiency anemia or thalassemia.

28
Mean corpuscular hemoglobin (MCH) is a calculation of the average amount
of oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are
large so they tend to have a higher MCH, while microcytic red cells would
have a lower value.

Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the

average concentration of hemoglobin inside a red cell. Decreased MCHC
values (hypochromia) are seen in conditions where the hemoglobin is
abnormally diluted inside the red cells, such as in iron deficiency anemia and
in thalassemia. Increased MCHC values (hyperchromia) are seen in
conditions where the hemoglobin is abnormally concentrated inside the red
cells, such as in burn patients.

Normal Dates
Tests Aug 05 Aug 13
(Reference) Values
MCV 80-94 fL 94.0 94.0
MCH 27.0-31.0 pg 30.8 30.8
MCHC 33.0-37.0 g/dl 32.8() 32.9()
RDW 11-16 % 12.1 12.3

Red cell distribution width (RDW) is a calculation of the variation in the size of
RBCs. In some anemias, such as Pernicious anemia, the amount of variation
(anisocytosis) in RBC size (along with variation in shape – poikilocytosis)
causes an increase in the RDW.
Many conditions will result in increases or decreases in the cell populations.
Some of these conditions may require treatment, while others will resolve on
their own. Some diseases, such as cancer (and chemotherapy treatment),
can affect bone marrow production of cells, increasing the production of one
cell at the expense of others or decreasing overall cell production. Some
medications can decrease WBC counts while some vitamin and mineral
deficiencies can cause anemia.

Serum Electrolytes

29
Calcium (Ca++) is a major cation in teeth and bones and is found in fairly equal
concentrations in both ECF and ICF (Intracellular fluid). Aside ffrom helping
muscles contract, calcium also affects cell membrane permeability and firing
level and also aids in coagulation.
High levels of calcium ions (hypercalcemia) occur when the body dissolves
bone at an abnormally fast rate, increasing both serum calcium and serum
phosphate. Sudden hypercalcemia can cause vomiting and coma, while
prolonged and moderate hypercalcemia results in the deposit of calcium
phosphate crystals in the kidneys and eye.
Hypocalcemia can result from hypoparathyroidism (low parathyroid hormone)
and from phosphate poisoning (the phosphate enters the bloodstream and
forms a complex with the free serum calcium) that can cause depression and
muscle spasms.
The most abundant mineral in the body, it is involved in bone metabolism,
protein absorption, fat transfer muscular contraction, transmission of nerve
impulses, blood clotting, and cardiac function. It is highly sensitive to elements
such as magnesium, iron, and phosphorus as well as hormonal activity,
vitamin D levels, alkalinity and acidity, and many drugs.
Phosphorus is an abundant element found in most tissues and cells. It is
closely related to the calcium level with an inverse relationship. When calcium
is increased, phosphorus tends to decrease and vice versa. Careful following
of blood draw procedures are necessary because improper handling may
cause falsely elevated values. Phosphorus is needed for its buffering action,
calcium transport, and osmotic pressure.

Reference Date
Electrolyte 13 August 2010
Value
Calcium 8.4-10.4 mg/dl 8.8 mg/dl
Phosphorus 2.5-4.7 mg/dl 3.9 mg/dl
*Deviations from the Normal (Reference) Values are indicated by arrows ()
or ().

Blood Urea Nitrogen (BUN)

The BUN test is primarily used, along with the creatinine test, to evaluate
kidney function in a wide range of circumstances, to help diagnose kidney

30
disease, and to monitor patients with acute or chronic kidney dysfunction or
failure. It is also used as part of a routine testing panel to check how the
kidneys are functioning and like the LFTs, before starting and during certain
drug treatments.
Increased BUN levels suggest impaired kidney function. This may be due to
acute or chronic kidney disease, damage, or failure. It may also be due to a
condition that results in decreased blood flow to the kidneys, to conditions that
cause obstruction of urine flow, or to dehydration. Excessive protein
breakdown (catabolism), an increased protein intake or even gastrointestinal
bleeding can elevate BUN concentrations in the blood.
Low BUN levels are not common and are not usually a cause for concern.
They may be seen in severe liver disease, malnutrition, and sometimes when
a patient is overhydrated (too much fluid volume), although the test is not
usually used to monitor these conditions.

Normal Date
Tests 03 August 13 August
(Reference) Values
BUN 7.0-18.0 mg/dl 14.92 15.0
*Deviations from the Normal (Reference) Values are indicated by arrows ()
or ().

Creatinine
The creatinine blood test may be ordered, along with BUN test and
microalbumin, at regular intervals when a patient has a known kidney disorder
or has a disease that may affect kidney function or be exacerbated by
dysfunction. Both BUN and creatinine may be ordered when a CT scan is
planned (as was planned for this patient upon admission), prior to and during
certain drug therapies (in this case, chemotheraphy), and before and after
dialysis to monitor the effectiveness of treatments.
Creatinine is the waste product of muscle metabolism. Its level is a reflection
of the body's muscle mass. Low levels are sometimes seen in kidney
damage, protein starvation, liver disease, or pregnancy. Elevated levels are
sometimes seen in kidney disease due to the kidneys job of excreting

31
creatinine, muscle degeneration, and some drugs involved in impairment of
kidney function.

Creatinine Levels (NV: 0.6-1.5 mg/dl)

2
1.6
1.5 1.4 1.4 1.4
mg/dl 1 0.9 0.9
0.8 0.7
0.5

0
20-Jul 3-Aug 12-Aug 12-Aug 13-Aug 15-Aug 19-Aug 26-Aug
Dates

URIC ACID

Uric acid is the end product of purine metabolism and is normally excreted
through the urine. High levels are noted in gout, infections, kidney disease,
alcoholism, high protein diets, and with toxemia in pregnancy. Low levels may
be indicative of malabsorption, a diet low in purines, liver damage, or an
overly acid kidney.

Normal Date
Tests 13 Aug
(Reference) Values
Uric Acid 3.0-8.0 mg/dl 2.7 mg/dl ()
*Deviations from the Normal (Reference) Values are indicated by arrows () or ().

ALBUMIN

Albumin is the major constituent of serum protein (usually over 50%). It is

manufactured by the liver from the amino acids taken from the diet. It helps in
osmotic pressure regulation, nutrient transport, and waste removal. High
levels are rarely seen and are primarily due to dehydration. Low levels are
seen in poor diets, diarrhea, fever, infection, liver disease, inadequate iron
intake, third-degree burns and edemas, and hypocalcemia.

32
 Normal Date
Tests 13 Aug
(Reference) Values
Albumin 3.5-5.0 mg/dl 3.8 mg/dl
*Deviations from the Normal (Reference) Values are indicated by arrows ()
or ().

Lipids
CHOLESTEROL

Cholesterol is a critical fat that is a structural component of cell membrane

and plasma lipoproteins, and is important in the synthesis of steroid
hormones, glucocorticoids, and bile acids. Mostly synthesized in the liver,
some is absorbed through the diet, especially one high in saturated fats. High
density lipoproteins (HDL) is desired as opposed to the low density
lipoproteins (LDL), two types of cholesterol. Elevated cholesterol has been
seen in artherosclerosis, diabetes, hypothyroidism, and pregnancy. Low levels
are seen in depression, malnutrition, liver insufficiency, malignancies, anemia,
and infection.

Cholesterol Level (NV: 120-240

mg/dl)

400
356
300
mg/dl 200 205
128
100
0
20-Jul 19-Aug 26-Aug
Dates

TRIGLYCERIDES

33
Triglycerides, stored in adipose tissues as glycerol, fatty acids and
monoglycerides, are reconverted as triglycerides by the liver. Ninety percent
of the dietary intake and 95% of the fat stored in tissues are triglycerides.
Increased levels may be present in artherosclerosis, hypothyroidism, liver
disease, pancreatitis, myocardial infarction, metabolic disorders, toxemia, and
nephrotic syndrome. Decreased levels may be present in chronic obstructive
pulmonary disease, brain infarction, hyperthyroidism, malnutrition, and
malabsorption.

Triglycerides(NV:0-200mg/dl)

400
350.93
300

mg/dl 200 191

100 82
0
20-Jul 19-Aug 26-Aug
Dates

GLUCOSE (Fasting Blood Glucose)

Glucose, formed by the digestion of carbohydrates and the conversion of

glycogen by the liver, is the primary source of energy for most cells. It is
regulated by insulin, glucagon, thyroid hormone, liver enzymes, and adrenal
hormones. It is elevated in diabetes, liver disease, obesity, pancreatitis, due to
steroid medications, or during stress. Low levels may be indicative of liver
Fasting Blood Sugar (NV: 75-115 mg/dl)
disease, overproduction of insulin, hypothyroidism, or alcoholism.
200

150 156.32 148.88 150

123
mg/dl 100
88.77 89.45
50

0
20-Jul 27-Jul 3-Aug 12-Aug 19-Aug 26-Aug
Dates
34
Liver Function Tests
Liver function tests help diagnose liver disorders if suggestive symptoms are
present. The pattern of the blood results may help to say which disorder is
causing the problem depending on which enzyme is highest. It may also be
done as a routine precaution after starting certain medicines to check that
they are not causing liver damage as a side-effect.
Alanine transaminase (ALT) is an enzyme that helps to process proteins.
Large amounts of ALT occur in liver cells so when the liver is injured or
inflamed, as in hepatitis, the blood’s ALT level usually rises. ALT is the most
accurate enzyme in assessing liver function.
The patient’s ALT levels were within normal values indicating no liver
disorder.
Bilirubin is the chemical that gives bile its yellow to green color. A high level of
bilirubin in a person’s blood causes the skin to appear jaundiced or 'yellow'.
Bilirubin is made from hemoglobin.
Hemoglobin is a chemical in red blood cells that is released when the red
blood cells break down. Liver cells take in bilirubin and attach sugar
molecules to it. This is then called direct (conjugated) bilirubin which is passed
into the bile ducts. A raised blood level of conjugated bilirubin occurs in
various liver and bile duct conditions. It is particularly high if the flow of bile is
blocked as by a tumor in the pancreas. It can also be raised with hepatitis,
liver injury, or long-term alcohol abuse.
A raised level of indirect (unconjugated) bilirubin occurs when there is
excessive breakdown of red blood cells as in hemolytic anemia.

35
Globulins or immunoglobulins are important in protein metabolism. The type
of immunoglobulin is specific in different liver disorders but an increase in
globulin usually indicates hepatitis and liver or biliary cirrhosis.

HbA1C test (Hemoglobin A1C).

This test is a measure of the patient’s compliance to his drug treatment. If the
patient is dutifully taking in his medicine, the obtained result would be normal.
If the patient is not complying with his medications, then the result is elevated.
It is good that people become aware of these different tests, so that they
would be able to monitor their glucose levels or that of diabetic relatives and
friends.

Normal Date
Tests Aug 05
(Reference) Values Aug 12
Alkaline Phosphatase 45-122 U/L 59 -
Total Bilirubin (TB) 0.0-1.0 mg/dl 0.8 -
B2 (Direct Bilirubin) 0.0-0.3 mg/dl 0.4 () -
B1 (Indirect Bilirubin) 0.0-0.7 mg/dl 0.4 -
HBA1C (IFCC-new method) 2.9-4.2 % 6.2() -
HBA1C(DCCT-old method) 4.8-5.9 % 7.7()
SGPT-ALT 10-44 U/L 110()
Sodium (Serum) 134.0-148.0 mmol/L 136.0 -
Potassium 3.3-5.3 mmol/L 3.9 -
*Deviations from the Normal (Reference) Values are indicated by arrows ()
or ().

Reference value for this result is between 0-115 U/L.
Urinalysis
Urinalysis is the physical, chemical, and microscopic examination of urine. It
involves a number of tests to detect and measure various compounds that
pass through the urine. It may be done as part of a routine medical exam to
screen for early signs of disease; to monitor signs of diabetes or kidney
disease; to check for blood in the urine; and to diagnose urinary tract
infections. It is ordered widely and routinely to detect any abnormalities that
require follow up.

36
 Urinalysis results can have many interpretations. Abnormal findings are a
warning that something may be wrong and should be evaluated further.
Generally, the greater the concentration of the atypical substance, such as
greatly increased amounts of glucose, protein, or red blood cells, the more
likely it is that there is a problem that needs to be addressed.

Normal Dates
Urinalysis
Values 17 Jul 24 Jul 28 Jul 13 Aug 17 Aug
yellow
Color yellow yellow yellow Yellow Yellow
amber
Transparency clear cloudy clear clear Clear Clear
Reaction 4.8-7.8 6.0 6.0 6.0 6.0 6.5
1.015-
Specific gravity 1.010 1.010 1.005 1.010 1.010
1.025
negativ
Sugar Positive Trace negative negative Positive
e
negativ
Protein Trace Positive negative negative Negative
e
RBC 0-1/hpf 3-6/hpf 2-5/hpf 0-1/hpf 0-1/hpf 0-1/hpf
Pus cells 0-2/hpf 0-2/hpf 0-1/hpf 0-1/hpf 0-1/hpf 0-1/hpf
few
Epithelial cells rare rare rare rare rare
present
*Deviations from the Normal Values are shown in red ink.

The depth of urine color is a crude indicator of urine concentration: pale

yellow or colorless urine indicates dilute urine where lots of water is being
excreted. Dark yellow urine indicates concentrated urine and the excretion of
waste products in a smaller quantity of water, such as is seen with the first
morning urine, with dehydration, and during a fever.
Urine transparency refers to how clear the urine is. Terms used in describing
urine clarity: clear, slightly cloudy, cloudy, or turbid. Substances that cause
cloudiness are mucus, epithelial cells, normal urine crystals, red blood cells,
white blood cells, and bacteria.
Specific gravity is a physical characteristic of the urine, a measure of urine
concentration that can be determined using a chemical test. There are no
“abnormal” specific gravity values. So a specific gravity of 1.005 may have

37
been brought about by the Intravenous fluids (IVFs) infused into the patient
since admission.
Protein is not normally detectable in urine. An elevation in urine protein,
called proteinuria, is usually an early sign of kidney disease. Sugar or
glucose is also not normally seen in normal urine. Increased glucose levels,
called glucosuria, may be caused by medications or could mean disorders like
diabetes mellitus.
A small number of RBCs is normally present in urine. However, when the
number of RBCs increases, they are detected as a “positive” test result and
this, in urine, is significant.
Cells, crystals, and other substances are counted and reported either as the
number observed “per low power field” (LPF) or “per high power field” (HPF).
Some entities are estimated as “few”, “moderate”, or “many”, such as
epithelial cells, bacteria, and crystals. Crystals are considered “normal” if they
are from solutes that are typically found in the urine like the one seen in the
patient’s urine: Calcium oxalate.

Chest X-ray
Chest radiography or simply, chest x-ray, is a painless diagnostic test
that evaluates the structure of the chest, lungs, heart, large arteries, ribs, and
diaphragm.
Date Requested: 19 July 2010
Clinical Data:
Both lung fields are clear, the heart is normal in size, shape, and
position. The trachea is at the midline both hemidiaphragms are sharp and
distinct. The osseous thoracic cage showed no significant bony abnormality.

Conclusion: NORMAL CHEST FINDINGS

Date and Time Requested: 12 2335H August 2010

Clinical Data:

38
 The lungs are clear, heart is not enlarged. Aorta is tortous and
sclerotic, the tracheal air column is at the midline. Both hemidiaphragms and
costophrenic sulci are intact. There are osteophytes arising from the lateral
articulating margins of the lower thoracic spine. The rest of the visualized
bong structures are unremarkable.
CONCLUSION:
o Tortuous and atheromatous aorta
o Hypertrophic degenerative changes of the thoracic spine, mild.
Medical sonography (ultrasonography) is an ultrasound-based
diagnostic medical imaging technique used to visualize muscles, tendons, and
many internal organs, to capture their size, structure and any
pathological lesions with real time tomographic images. Ultrasound has been
used by radiologists and sonographers to image the human body for at least
50 years and has become one of the most widely used diagnostic tools in
modern medicine. The technology is relatively inexpensive and portable,
especially when compared with other techniques, such as magnetic
resonance imaging (MRI) and computed tomography (CT). Ultrasound is also
used to visualize fetuses during routine and emergencyprenatal care. Such
diagnostic applications used during pregnancy are referred to asobstetric
sonography.

Date Requested: 20 July 2010

Clinical Data:
Reports:
Right Kidney: 11.2 x 6.7 x 7.0 cm
Left kidney: 8.6 x 3.2 cm (?)
Slightly enlarged liver with homogenous mildly hyperechogenic
parenchyural pattern.
No focal urase lesion seen.
Gallbladder is normally outlined & physiologically disturbed.
An intense echo with acoustic shadowing noted within the gallbladder
measuring about 8mm in its width dimension.

39
 Right kidney is slightly enlarged with 1:1 corticonudallary ratio. No
lithiasis nor coliectasis noted.
Left kidney is poorly visualized, a kidney-like noted measuring about
8.6x3.2cm (?) noted.
However, its cortex and prudulla are poorly delineated.
Urinary bladder is unusual in length.
REMARKS:
o MILD FATTY LIVER
o CHOLELITHIASIS, NON OBSTRUCTIVE
o SLIGHT FULAGID RIGHT KIDNEY
COMPENSATORY.
Date Requested: 13 August 2010
Examination: Kidneys, Ureter, Urinary Bladder, Prostate
Clinical Data:
Reports:
Right Kidney: 12.6 x 6.4 x 4.6 cm Cortical Thickness: 1.6 cm
Left kidney: --------------------cm------------- cortical thickness ---------cm
Prostate: 3.7 x 3.8 x 3.8 cm or approximately 29.4 gms
The right kidney is slightly enlarged. Parenchymal echo genicity is
hypoechoic are not prominent. No definite calculi or ectasia noted.
The left renal fossa is apparently empty. No normal or abnormal
looking left kidney is seen along the course of the ureter.
The prostate is enlarged, approximately 29.4 gms. Anatomic and
surgical capsules are intact.
The urinary bladder is well distended. Walls are smooth and
homogenously echogenic. No abnormal intraluminal echoes noted. No areas
of focal thickening, cellule or diverticle formation.
IMPRESSION:
Non visualized left kidney. Considerations include severe contraction,
ectopia or even congenital absence.
Top normal sized, otherwise structurally unremarkable right kidney,
most likely compensatory in nature.
Enlarged prostate, approximately 29.4 gms or Grade I.

40
Structurally unremarkable unrinary bladder.

41