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 2
nd

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 might
have 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
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
- RR 19 breaths/minute
- Temp 37 C

September 3, 2014
18 hours after PTBD insertion, 170 cc bile with blood clots were collected. At 4am patient had
febrile episode; temp 37.8 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.
















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