Choledocholithiasis: A Case Study of

St.
Paul University Quezon City College of Health Sciences

AURORA BLVD., COR GILMORE AVENUE, QUEZON CITY
A Case Study of
Choledocholithiasis
In partial fulfillment of the requirements in Related Learning Experience (NCM 08 LAB)
Submitted by: Largoza, Jeffrey Sale, Janelle Kate DC.
Submitted to: Col. Alma Bella Ancheta
I. INTRODUCTION
A. Background of the study Choledocholithiasis is the presence of at least one gallstone in the common bile duct. The stone may be made up of bile pigments or calcium and cholesterol salts. About 15% of people with gallstones will develop stones in the common bile duct, the small tube that carries bile from the gallbladder to the intestine. Risk factors include a history of gallstones. However, choledocholithiasis can occur in people who have had their gallbladder removed. MORE!!!!!!
B. Objectives General: Knowledge To gain knowledge and be aware of the disease. Skills To give proper care and medication to the patient. Attitude To develop self- confidence on the field of the chosen profession. Specific: Knowledge To gain more knowledge about Choledocholithiasis. To know its predisposing factors and ways to prevent it. Skills To develop skills on assessing and caring patients with Choledocholithiasis. Interpret the laboratory results of the patient. Present a specific, measurable, attainable, realistic and time-bounded nursing care plans for the client. Provide the patient and family with proper discharge plan (M.E.T.H.O.D). Outline recommendations based on the case studys findings. Attitude To establish trust and good Nurse- Patient- Interaction during one on one and interviews. To establish rapport to the patient and to the patients significant others.
C. Scope and Delimitation of the study The case study included all the facts regarding Choledocholithiasis (the definition, pathophysiology, signs and symptoms and treatment). The study was limited to TSGT A. J. L., one of the patients in Male Surgical Ward of Manila Naval Hospital.
D. Nursing Theory Florence Nightingales Environmental Theory: We applied Nightingales Environmental Theory through: Checking the patients body temperature, room temperature, ventilation and foul odors. Checking room for adequate light. Sunlight is beneficial to the patient. Creating and implementing adequate light in the room without placing the patient in direct light. Checking room for dust, dampness and dirt. Attempting to keep noise level in minimum. Checking bed and beddings for dampness, wrinkles and soiling. Attempting to keep the patient dry and clean at all times. Avoiding talking without giving advice that is without fact. Respecting the patient as a person and avoid personal talk. Checking the diet of the patient and noting the amount of food and fluid ingested by the patient at every meal. Documenting the plan of care and evaluating the outcomes to ensure continuity. Observing and recording anything about the patient.
II. CLINICAL SUMMARY

A. General Data Name: TSGT A.J.L. B.O.S.: Address: Age: 46 y/o Religion: Roman Catholic Civil Status: Married Nationality: Filipino Date of Birth: January 29, 1966 Date/time of Admission: June 28, 2012 / 1500H Ward and Room: Male Surgical Ward - 12 Admitting Diagnosis: Obstructuve Jaundice probably secondary to choledocholithiasis; cholecystolithisis; Diabetes Mellitus type II suspect. Attending Physician: Sources of Information: Verbalized by the patient and patients chart B. Chief Complaint: Epigastric pain with sharp in character verbalized by the patient. C. History of Present Illness AFPMC: The present condition started six months prior to admission; he experienced epigastric pain, colicky in character, non-radiating. No other associated signs and symptoms such as jaundice, fever, acholic stool and tea-colored urine. He sought consult wherein ultrasound was done which revealed Cholecystolithiasis. Patient was advised surgery and was lost to follow up. Three weeks prior to admission, there is recurrence of epigastric pain with sharp in character. No jaundice and fever was noted. He sought consult in AFPMC and ultrasound was done revealing dilated common bile duct. He was advised surgery but did not comply. Four days prior to admission, still with epigastric pain with jaundice. Patient was subsequently admitted.
MNH: Patient is diagnosed core of Choledocholithiasis, Cholecystolithiasis S/P admitted at Arm Forces of the Philippines Medical Center (AFPMC), T-tube insertion done and Cholecystectomy were done then eventually retroevac in Manila Naval Hospital (MNH).
D. Past Medical History Childhood Illness: Immunization: Accidents: Hospitalization: Medications: E. Familial History The patient said that they have a history of Diabetes Mellitus Type II.
F. Psychosocial Health

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St.

Paul University Quezon City College of Health Sciences

Submitted by: Largoza, Jeffrey Sale, Janelle Kate DC.

Submitted to: Col. Alma Bella Ancheta

II. CLINICAL SUMMARY

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