Department of Family and Community Medicine

Brokenshire Integrated Health Ministries Inc.

Madapo Hills, Davao City

Gallera, Alma S.
Monsanto, Melody Kaye
Tadlas, Joevet T.

Post Graduate Interns

2017-2018
GENERAL OBJECTIVES

1. To discuss a case of a 46-year old, male who came in in this institution with an

abdominal pain.

2. To briefly discuss a general approach in maintaining good control of a medical condition

3. To take into considerations in par with the medical case of patient’s biomedical and

psychosocial impact of the illness as well as of the family’s.

SPECIFIC OBJECTIVES

1. To have a thorough discussion of the biomedical aspect of the index patient’s condition

2. To briefly discuss Cholelithiasis guidelines and relate it to the case

3. To discuss the patient’s psychosocial aspect at par with his condition

4. To discuss in the analysis of the family’s dynamics using the appropriate assessment tools

5. To discuss the formulated biomedical and psychosocial wellness plans for each of the family

members

6. To discuss the family problems leading to family dysfunction and interventions

MEDICAL SCENARIO
General Data
E.A, a 46-year old, male, married, Filipino, Roman Catholic, PUJ Operator, was born on
April 25, 1971 in Lupon, Davao Oriental currently residing at Blk. 19, Lot 11,Ezekiel St. Emily
Homes, Cabantian, Davao City admitted for the first time in this institution.
Informant
Patient with 100% reliability

Chief Compliant
Abdominal pain
History of Present Illness
4 months prior to admission, patient had sudden onset of intermittent abdominal pain prominent
in the right upper quadrant area stabbing in character, with PS of 5/10, non-radiating, aggravated
upon exertion and movement, associated with nausea and vomiting of saliva, 4x; no febrile
episodes, no dizziness, no dyspnea. Patient sought consult with attending physician, ultrasound
of whole abdomen was initially ordered which revealed acalculous cholecystitis and tiny polyps;
Patient was advised for surgical intervention but did not comply instead opted for medical
management. Patient was given unrecalled pain reliever which gave temporary relief. Patient
tolerated condition.
A week prior to admission, recurrence of pain noted, now with nausea and vomiting of previously
ingested food, 2x, approximate of ½ glass per episode. No other associated signs and symptoms.
No consult done. No medications taken. Patient tolerated condition.
5 hours prior to consult, patient symptoms persisted, condition worsened, right upper quadrant
pain, PS now 10/10, patient cannot tolerate condition, sought consult in this institution and was
subsequently admitted.

Past Medical History

Patient is non diabetic, non-hypertensive, non-asthmatic, no known allergies to foods and drugs,
no previous hospitalizations and no surgical operations, no maintenance medications.

Family History
Patient’s father is diagnosed of Diabetes Mellitus type II while his mother is diagnosed of
Hypertension stage II.There were no heredo-familial diseases trace of cancer, bronchial asthma,
endocrine and cardiovascular diseases.

Personal & Social History

Patient is a graduate of vocational course for 7 months as a caregiver and 6 months in automotive.
He is married for 14 years, and has 1 child whom he is currently living with. He is a PUJ operator
and owns 2 jeepneys. Family’s financial assistance is mostly provided by him, and is supported
with his wife who is a Primary teacher. Patient has no known food and drug allergies. He is non-
smoker and non-alcoholic drinker.

Review of System:
General: No history of weight loss and fatigue. No fever or chills reported.
Eyes: No blurring of vision, no history of glaucoma or cataract.
Ear, Nose, and Throat: No vertigo reported. No frequent sore throat nor is there nosebleed.
Respiratory: No shortness of breath nor persistent cough reported.
Cardiovascular: No chest pain reported.
Gastrointestinal: No constipation. Patient reported abdominal pain on the right upper quadrant
area
Genitourinary: Neither pain nor burning sensation upon urinating. No hematuria reported.
Musculoskeletal: No intermittent weakness of both lower extremities and back pain reported.

Physical Examination
General Survey: Patient is awake, conscious, in pain, not in respiratory distress with the
following vital signs:
BP: 130/90 mm Hg, right arm
HR: 84 bpm, bounding, regular
RR: 24 cpm
TEMP: 36.5 ° C
O2sat 99%
Wt: 79 kgs
Ht: 5’7”
BMI: 27 kg/m2 (overweight)

Skin: warm to touch, good skin turgor and mobility

HEENT: anicteric sclera, pale palpebral conjunctiva, (-) naso-aural discharges, moist oral
mucosa
Chest/Lungs: clear breath sounds, equal chest expansion,
Cardiovascular: adynamic precordium, distinct heart sounds, normal rate, regular rhythm, (-)
murmurs
Abdomen: soft, flabby, (+) direct tenderness on the RUQ, (+) murphy’s sign
GUT: grossly male, (-) KPS
DRE: good sphincter tone, (-) tenderness, (-) mass, (-) blood and fecal material on examining
finger
Extremities: strong peripheral pulse, CRT <2 sec, (-) edema
Neurologic Examination:
Cerebral: alert, awake, coherent, oriented to time, place, and person
Cerebellar: normal gait, smooth and coordinated rapid alternating movements
Cranial Nerves:
I: unable to perform
II, III: (+) pupillary light reflex, direct and consensual in each eye
III, IV, VI: smooth & full range of extra-ocular muscle movement by Finger Following Test
V: (+) corneal reflex, strong & symmetrical muscles of mastication, intact facial sensation
VII: no facial asymmetry, facial expressions symmetrical
VIII: can hear spoken voice at 2 feet
IX, X: (+) gag reflex, able to swallow without difficulty, uvula at midline at rest and upon
phonation
XI: able to shrug both shoulders against resistance
XII: tongue at midline at rest and on protrusion
Sensory: intact sensation to pain and light touch on upper and lower extremities
Motor: good muscle tone, no tremors, no fasciculations,
Muscle strength:
5/5 5/5
5/5 5/5

Reflexes:

Salient Features:

 46-year old
 Male
 79 kgs
 BMI: 27 kg/m2
 sudden onset of intermittent abdominal pain
 prominent in the right upper quadrant area, PS of 5/10, non-radiating,
 nausea and vomiting
 (+) direct tenderness on the RUQ
 (+) murphy’s sign
Differential Diagnosis:
Appendicitis
Rule In: abdominal pain, nausea and vomiting
Rule out: prominent in the right upper quadrant area
Acute Gastroenteritis
Rule in: abdominal pain, nausea and vomiting
Rule out: cannot totally rule out
Acute uncomplicated Urinary Tract Infection
Rule in: abdominal pain, nausea and vomiting
Rule out: no dysuria, (-) KPS, no febrile episodes
Cholelithiasis
Rule in: abdominal pain prominent in the RUQ area, nausea and vomiting, (+) murphy’s
sign
Rule out: cannot totally rule out

Acute Gastroenteritis Cholelithiasis

46 years old
Male
79 kgs (BMI: 27 kg/m2)
sudden onset of intermittent
abdominal pain
prominent in the right upper
quadrant area
nausea and vomiting
(+) direct tenderness on the
RUQ
(+) murphy’s sign
 
 
X 
 
 
 
 
 

Admitting Diagnosis:
Cholelithiasis

Course in the Ward

12/16/17 Upon Admission
 Subjective Objective Assessment Plan
Patient complained of - Stable VS Cholelithiasis - Secure consent to care
Right Upper Quadrant - Anicteric sclerae, Pink - NPO temporarily
pain, non-radiating Palpebral Conjunctivae - V/S q4
- Equal chest - I&O q shift
expansion, Clear - IVF: D5LR 1L @ 120 cc/hr
breath sound - Labs:
- Adynamic precordium, 1. CBC 6 hours post vomiting
Distinct heart sounds 2. UA
- (+) direct tenderness 3. USD WA
on the RUQ, (+) 4. S.electrolytes
5. S.crea
murphy’s sign 6. SGPT
- Strong pulses, CRT 7. ECG
<2 seconds - Meds:
1. HNBB 1amp IVTT q8 PRN for
abdominal pain
2. Metoclopramide 1 amp IVTT q8
then PRN for vomiting
- Watch out for persistence of
abdominal pain, vomiting and
other unusalties
- Co- management with Dr,
Puracan

Case Discussion:

ANATOMY
Gallbladder
The gallbladder is a pear-shaped sac, about 7 to 10 cm long, with an average capacity of 30 to
50 mL
The gallbladder is located in a fossa on the inferior surface of the liver.
The gallbladder is divided into four anatomic areas: the fundus, the corpus (body), the
infundibulum, and the neck. The fundus is the rounded, blind end that normally extends 1 to 2 cm
beyond the liver’s margin.
It contains most of the smooth muscles of the organ, in contrast to the body, which is the main
storage area and contains most of the elastic tissue. The body extends from the fundus and tapers
into the neck, a funnel-shaped area that connects with the cystic duct. The neck usually follows a
gentle curve, the convexity of which may be enlarged to form the infundibulum or Hartmann’s
pouch. The neck lies in the deepest part of the gallbladder fossa and extends into the free portion
of the hepatoduodenal ligament.
The cystic artery that supplies the gallbladder is usually a branch of the right hepatic artery (>90%
of the time). The course of the cystic artery may vary, but it nearly always is found within the
hepatocystic triangle, the area bound by the cystic duct, common hepatic duct, and the liver
margin (triangle of Calot).
Venous return is carried either through small veins that enter directly into the liver or, rarely, to a
large cystic vein that carries blood back to the portal vein. Gallbladder lymphatics drain into nodes
at the neck of the gallbladder. Frequently, a visible lymph node overlies the insertion of the cystic
artery into the gallbladder wall. The nerves of the gallbladder arise from the vagus and from
sympathetic branches that pass through the celiac plexus.

Physiology
The liver produces bile continuously and excretes it into the bile canaliculi. The normal adult
consuming an average diet produces within the liver 500 to 1000 mL of bile a day. The secretion
of bile is responsive to neurogenic, humoral, and chemical stimuli.
Hydrochloric acid, partly digested proteins, and fatty acids in the duodenum stimulate the release
of secretin from the duodenum that, in turn, increases bile production and bile flow. Bile flows
from the liver through to the hepatic ducts, into the common hepatic duct, through the common
bile duct, and finally into the duodenum. With an intact sphincter of Oddi, bile flow is directed into
the gallbladder.
Bile is mainly composed of water, electrolytes, bile salts, proteins, lipids, and bile pigments.
Sodium, potassium, calcium, and chlorine have the same concentration in bile as in plasma or
extracellular fluid
Bile salts are excreted into the bile by the hepatocyte and aid in the digestion and absorption of
fats in the intestines.6
In the intestines, about 80% of the conjugated bile acids are absorbed in the terminal ileum. The
remainder is dehydroxylated (deconjugated) by gut bacteria, forming secondary bile acids
deoxycholate and lithocholate. These are absorbed in the colon, transported to the liver,
conjugated, and secreted into the bile. Eventually, about 95% of the bile acid pool is reabsorbed
and returned via the portal venous system to the liver, the so-called enterohepatic circulation. Five
percent is excreted in the stool, leaving the relatively small amount of bile acids to have maximum
effect.
Cholesterol and phospholipids synthesized in the liver are the principal lipids found in bile.
The color of the bile is due to the presence of the pigment bilirubin diglucuronide, which is the
metabolic product from the breakdown of hemoglobin and is present in bile in concentrations
100 times greater than in plasma. Once in the intestine, bacteria convert it into urobilinogen, a
small fraction of which is absorbed and secreted into the bile.
Gallbladder Function
The gallbladder, the bile ducts, and the sphincter of Oddi act together to store and regulate the
flow of bile. The main function of the gallbladder is to concentrate and store hepatic bile and to
deliver bile into the duodenum in response to a meal.

Diagnostic Studies:
Blood tests:

 complete blood count

 liver function tests
An elevated white blood cell (WBC) count may indicate or raise suspicion of cholecystitis. If
associated with an elevation of bilirubin, alkaline phosphatase, and aminotransferase, cholangitis
should be suspected. Cholestasis, an obstruction to bile flow, is characterized by an elevation of
bilirubin (i.e., the conjugated form) and a rise in alkaline phosphatase. Serum aminotransferases
may be normal or mildly elevated. In patients with biliary colic or chronic cholecystitis, blood tests
will typically be normal.

Ultrasonography
 An ultrasound is the initial investigation of any patient suspected of disease of the biliary
tree.
 It is noninvasive, painless, does not submit the patient to radiation, and can be performed
on critically ill patients.

Biliary Radionuclide Scanning (HIDA Scan)

 Provides a noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with
both anatomic and functional information.
 The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis, which
appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and
duodenum.

Computed Tomography
 Abdominal CT scans are inferior to ultrasonography in diagnosing gallstones.
 The major application of CT scans is to define the course and status of the extrahepatic
biliary tree and adjacent structures.
 It is the test of choice in evaluating the patient with suspected malignancy of the
gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of
the pancreas

Percutaneous Transhepatic Cholangiography

 Intrahepatic bile ducts are accessed percutaneously with a small needle under
fluoroscopic guidance.
 Has little role in the management of patients with uncomplicated gallstone disease but is
particularly useful in patients with bile duct strictures and tumors, as it defines the anatomy
of the biliary tree proximal to the affected segment
Magnetic Resonance Imaging
 MRI provides anatomic details of the liver, gallbladder, and pancreas similar to those
obtained from CT
 It has a sensitivity and specificity of 95% and 89%, respectively, at detecting
choledocholithiasis

Endoscopic Retrograde Cholangiopancreatography

 The procedure requires intravenous (IV) sedation for the patient
 The advantages of ERC include direct visualization of the ampullary region and direct
access to the distal common bile duct, with the possibility of therapeutic intervention
 ERC is the diagnostic and often therapeutic procedure of choice

Endoscopic Ultrasound
 Endoscopic ultrasound requires a special endoscope with an ultrasound transducer at its
tip
 The results are operator dependent, but offer noninvasive imaging of the bile ducts and
adjacent structure

Gallstone disease
 One of the most common problems affecting the digestive tract
 The prevalence of gallstones is related to many factors, including age, gender, and ethnic
background
 Obesity, pregnancy, dietary factors, Crohn’s disease, terminal ileal resection, gastric
surgery, hereditary spherocytosis, sickle cell disease, and thalassemia are all associated
with an increased risk of developing gallstones
 Women are three times more likely to develop gallstones

Natural History
 Most patients will remain asymptomatic from their gallstones throughout life
 Some patients progress to a symptomatic stage, with biliary colic caused by a stone
obstructing the cystic duct
 Gallstones in patients without biliary symptoms are commonly diagnosed incidentally on
ultrasonography, CT scans, or abdominal radiography or at laparotomy

Gallstone Formation
Gallstones form as a result of solids settling out of solution. The major organic solutes in bile are
bilirubin, bile salts, phospholipids, and cholesterol.
 Cholesterol Stones
1. Pure cholesterol stones are uncommon and account for <10% of all stones. They
usually occur as single large stones with smooth surfaces.
2. Cholesterol is secreted into bile as cholesterol-phospholipid vesicles.
3. Cholesterol is held in solution by micelles, a conjugated bile salt-phospholipid-
cholesterol complex, as well as by the cholesterol-phospholipid vesicles
4. Vesicular maturation occurs when vesicular lipids are incorporated into micelles
  Pigment Stones
1. Pigment stones contain <20% cholesterol and are dark because of the presence
of calcium bilirubinate
2. Black pigment stones are usually small, brittle, black, and sometimes spiculated.
They are formed by supersaturation of calcium bilirubinate, carbonate, and
phosphate
3. Brown stones are usually <1 cm in diameter, brownishyellow, soft, and often
mushy. They may form either in the gallbladder or in the bile ducts, usually
secondary to bacterial infection caused by bile stasis. Precipitated calcium
bilirubinate and bacterial cell bodies compose the major part of the stone

FAMILY PROFILE

Name Age Educational Attainment Occupation

AA 46 Automotive PUJ operator
BA 36 College graduate/ BSEd Primary Teacher
CA 12 Grade 12 Student

Abrea’s family has 3 family members. BA, is the wife of the index patient. She is 36 years old.

She graduated with Bachelor of Science in Education and works as a Primary Teacher in a public

school. CA is the only son of the Abrea family. He is currently a Grade 12 student. He has been

excelling academically in which the family states that he is studying hard to become a doctor

someday. AA is the index patient,46 years old and has graduated an automotive course for 7

months. He has also graduated a 2 year course as a caregiver. Currently, he is working as a PUJ

operator and works 8 hours per day. He is the major caretaker of their son and devotedly given

utmost attention in caregiving.

FAMILY STRUCTURE

Abrea’s family is a nucler type of family. The married couple lives with their son under one roof.

No other family members lives with them.

FAMILY ECONOMIC STATUS

Abrea’s family belong to a middle-class earner. AA is earning approximately 30, 000 per monthly

from his PUJ operator. Her wife, BA is earning 23, 000 monthly. AA and BA has been very keen

in budgeting their income because both provide and divide expenses in their household. Their

partnership can be considered as a dual-earner relationship and both of them consider

themselves as breadwinners. Expenses are allocated in the beginning of the month in house bills

– electricity and water bills, groceries, school fees and allowances, medical fund and the

remaining are kept as savings. AA verbalized that money was never a start of the argument of

the married couple.

AA is the decision maker but still ask advices from his wife, BA. He would make sure that his

wife’s opinions and suggestions are taken into consideration.

AA is the primary caregiver of CA, knowing that he has more knowledge in caregiving because

he has graduated caregiving as a course. He also verbalized that his wife is a bit busy at school

and his is more flexible in taking care of their son.

FAMILY ENVIRONMENT

The family is residing in a secured subdivision wherein the family has already owned the house

several years ago. The house is a duplex type with 1 floor.

There is a comfortable receiving area which was also serves as the entertainment area of the

family. There is 1 bedroom in which the family share. They would sleep together in a queen-sized

bed. They have one clean bathroom. Their toilet is a flushed-typed.

At the back portion of their house a small backyard which serves as their laundry area.

Their drinking water is mineral water delivered by a nearby refilling station but what they are using

in bathing and in washing is the water in the faucet provided by water district.

Their house is located in St. Emily Homes, Cabantian, Davao City.