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VI. COURSE IN THE WARD
August 27, 2014
From St. Lukes Medical Center Outpatient Department, patient
sought consultation 3 weeks
prior. Patient reported pain to become severe (visual analogue
scale 10/10) prompted a follow-up
consult. He was then advised for surgery hence admission.
Patient was transferred via wheelchair and
was brought to Annex III Second East. He was given vitamin K,
antibiotics and pain medications. A series
of test were done. He was referred for Endoscopic Retrograde
Cholangiopancreatography ( ERCP ) and
sphincterotomy; a diagnostic test examining the bile and
pancreatic duct for any abnormalities such as
blockages, fluid flow, stones.
August 28, 2014
Vital signs were taken and recorded. Patient was referred to the
Urology for finding of renal
cortical cyst as it may have developed in one or both of the
kidneys. The procedure was not done since
the problem was located elsewhere.
August 30, 2014
Patient underwent ERCP and stone basket extraction; result was
biliary stricture probably 2nd
degree to extrinsic compression, multifunctional anemia, r/o
cholangiocarcinoma. Patient was being
monitored for possible bleeding complications, since an inflamed
pancreas might cause bleeding.
September 1, 2014
Patient was seen to be comfortable and seems to have tolerated
the procedure very well. There
was no chest pain or have any difficulty breathing. Vital signs:
BP 110/70, HR 70 beats/min, RR-19
breaths/min, temp- 37C; indicating that they were normal and
stable .The Attending nurse however
noted a (+) burning epigastric pain, (+) bloatedness, (+) tea
colored urine. It would seem that the
burning epigastric pain may be due to the procedure done
resulting in gas distension. The most
common discomfort after the exam is a feeling of bloating as air
was introduced gently to open up the
esophagus, stomach and intestine so the scope can be passed
through. Patient has jaundice that may be
due to obstruction of the bile duct causing the darkening of the
urine. (tea-colored).
September 2, 2014
At 3:30 pm, patient was under Percutaneous Transhepatic Biliary
Drainage insertion. This mighthave been done to allow the bile to
flow freely. ERCP results showed a biliary stricture in which
the
common bile duct is abnormally narrowed or obstructed, prompted
the PTBD insertion. This is a
procedure where a catheter is placed into the bile duct to allow
the bile to drain out into a bag outside
the body or into the small intestine. There was a need to drain
to relieve the blockage and for
monitoring the output. Procedure lasted for an hour and 4o
minutes. He tolerated the procedure well
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and had no signs of hypotension or fever. The following vital
signs were taken after the procedure
indicating stable vital signs and that the patient seemed to
have tolerated the procedure very well.
- BP - 110/70
- HR - 70 beats/minute
-RR19 breaths/minute
- Temp37 C
September 3, 2014
18 hours after PTBD insertion, 170 cc bile with blood clots were
collected. At 4am patient had
febrile episode; temp37.8 C. He was given 500 mg paracetamol.
Ideally patient must be afebrile 24
hours prior to discharge but doctor noted patient may go home
the next day. Patient was fit to be
discharged, was prescribed take home medications and was
instructed a follow-up at General Surgery-
OPD after 2 weeks.
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XI. DISCHARGE PLANNING
Patient may have been discharged 2 days after the procedure. The
following is a presumed discharge
planning for the patient.
Medication
- Inform the patient to take tramadol only when feeling pain
- Inform the patient or relative about the side effects of
medication such as headache,
drowsiness, lightheadedness.
Environment
- Encourage patient and family to have a quiet and stress free
environment that is beneficial to
patients progress on regaining back his energy.
Treatment
-Encourage the patient to increase oral fluid intake
- Inform the patient to return if there is complication and to
return for follow-up check-ups
Health teaching
- Promote the patient a good rest
- Restrict oneself to activities within reach
- Teach family or relatives how to flush the drainage to keep
the cleanliness.
Outpatient
- Inform the patient and family about the follow-up check-ups.
Upon check-ups, a recent CBC and
urinalysis must be presented.
Diet
- Encourage the patient to increase fluid intake
- Provide the patient a healthy diet, staying away from foods
high in cholesterol, calories and fats.
- Recommend patient to take multivitamins and minerals.
Spiritual
- Encourage to pray as a family for a fast recovery
