XIV. Genito-urinary
Pubic hair is present, thick in each strand, curly and equally distributed on the mons pubis. No vaginal bleeding or any other unusual discharges noted.
Page | 33 Patient voids freely. She has no difficulty urinating and did not report dysuria.
She verbalized her urine is amber in color.
XV. Neurological
Patient was received lying on bed, awake, conscious, coherent and afebrile. Reflexes are normal and symmetrical bilaterally in both extremities.
Patient is oriented to person, place and time. She has a Glasgow coma scale of 15: 4 from eye opening, 5 for verbal resoponse and 6 for motor response. She is also alert and attentive.
Page | 34 ANATOMY AND PHYSIOLOGY
GALLBLADDER
The gallbladder is a hollow organ that sits just beneath the liver. In adults, the gallbladder measures approximately
8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct. Its function is to store and release bile, a fluid made by the liver.
Page | 35 CYSTIC DUCT
The cystic duct is the short duct that joins the gall bladder to the common bile duct. The cystic duct varies from 2 to 3 cm in length and terminates in the gallbladder.
Throughout its length, the cystic duct is lined by a spiral mucosal elevation, called the valvula spiralis (valve of
Heister) which is
a series of crescentic folds of mucous
membrane in the upper part of the cystic duct, arranged in a somewhat spiral manner. Its length is variable and usually ranges from 2 to 4 cm.
The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology (stones or passed stones).
The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.
BILE
The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin.
Page | 36 Bile, is produced by hepatocytes in the liver and and then flows into the common hepatic duct, which joins with the cystic duct from the gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of Oddi, a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum, is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all the original organic molecules.
When food is released by the stomach into the duodenum in the form of chyme, the duodenum releases cholecystokinin, which causes the gallbladder to release the concentrated bile to complete digestion.
Bile helps to emulsify the fats in the food. Besides its digestive function, bile serves also as the route of excretion for bilirubin, a byproduct of red blood cells recycled by the liver.
The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum, the final section of the small intestine. Bile salts also act as bactericides, destroying many of the microbes that may be present in the food.
In the absence of bile, fats become indigestible and are instead excreted in feces, a condition called steatorrhea.
Page | 37 ETIOLOGY AND SYMPTOMATOLOGY
Etiology Predisposing
Factors
Present/
Absent Rationale Justification
Female PRESENT Women between 20 and 60 years of age are twice as likely to develop
gallstones as men.
Estrogen increases cholesterol levels in bile and decrease gallbladder movement, both of
which can lead to gallstones.
Sources:
Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1822
Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184
http://www.diabetesmonitor.com/learning-center/gallstones.htm
The patient is female.
Diabetes mellitus
ABSENT People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids increase the risk of gallstones.
Sources:
Harrison’s Principles of Internal Medicine,
The patient is not diabetic.
Page | 38 Tenth Edition 1983 page 1823
Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184
Age (20-50; over
age 60)
PRESENT Many of the body’s systems and protective mechanisms become less efficient with age. Body systems and
processes become sluggish.
Sources:
Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1823
Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184
The patient
PRESENT Native Americans have a genetic predisposition to secrete high levels
of cholesterol in bile. In fact, they have the highest rate of gallstones
in the United States. A majority of Native American men have gallstones by age 60. Mexican American men and women of all
ages also have high rates of gallstones.
Asians are more genetically predisposed to having pigment stones as compared to those living
The patient
Page | 39 in the Western countries
Sources:
Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184
http://www.diabetesmonitor.com/learning-center/gallstones.htm
Precipitating Factors
Present/
Absent Rationale Justification
Pregnancy
ABSENT Excess estrogen from pregnancy, hormone replacement therapy, or
birth control pills appears to increase cholesterol levels in bile
and decrease gallbladder movement, both of which can lead
to gallstones.
Source:
http://www.fbhc.org/Patients/Modul es/gallstns.cfm
The patient is not pregnant.
Rapid weight
loss ABSENT As the body metabolizes fat during rapid weight loss, it causes the liver
to secrete extra cholesterol into bile, which can cause gallstones.
Sources:
Lippincott Williams and Wilkins Handbook of Diseases Third
Edition, page 184
http://www.fbhc.org/Patients/Modul
Page | 40 Obesity ABSENT
The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases
gallbladder emptying.
Sources:
Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page
1823
Lippincott Williams and Wilkins Handbook of Diseases Third
Edition, page 184
http://www.fbhc.org/Patients/Modul es/gallstns.cfm
The patient is not obese.
Fasting ABSENT Fasting decreases gallbladder movement, causing the bile to become overconcentrated with
cholesterol, which can lead to gallstones.
PRESENT Excess estrogen from pregnancy, hormone replacement therapy, or
birth control pills appears to increase cholesterol levels in bile
and decrease gallbladder movement, both of which can lead
to gallstones.
Page | 41 Source:
Lippincott Williams and Wilkins Handbook of Diseases Third
Edition, page 184
http://www.diabetesmonitor.com/lea rning-center/gallstones.htm
Low Fat Diet PRESENT Before dietary fat can be digested, it has to be emulsified. Bile is used for this purpose. The liver makes bile continuously and stores it in the
gall bladder until such time as it is needed. However, if a low-fat diet is
eaten, that bile remains in the gall bladder.
Gallstones are formed when the gall bladder is not emptied on a
regular basis. In people who continually resort to low-fat diets, bile is stored for long periods in the
gall bladder — and it stagnates. In time — and it is really quite a short time — a 'sludge' begins to form.
Source:
http://www.second-opinions.co.uk/gallstones.html
The patient avoids fatty
foods.
Page | 42
Rationale Justification
Right upper
PRESENT Obstruction of ducts connected to the gallbladder will cause inflammation produced by increased intraluminal pressure and distension of the gallbladder.
Sources:
Harrison’s Principles of Internal Medicine, Tenth
Edition 1983 page 1825
The patient by endogenous pyrogens released from host cells in response to infectious or non-infections disorders. It may be brought about by prostaglandins released during inflammation.
Source: Carol Mattson
The patient
was not
febrile.
Page | 43 Porth (2005.
Pathophysiology, Seventh edition page 205)
Murphy's sign (abrupt interruption of
deep inspiration)
PRESENT Classically Murphy's sign is tested for during an abdominal examination;
it is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the
Page | 44 considered positive. A
positive test also requires no pain on performing the maneuver on the patient's left hand side.
Source:
http://www.turner-white.com/pdf/hp_nov00_m
urphy.pdf
Nausea and vomiting
ABSENT Nausea and vomiting sometimes occur with biliary colic. The inflammation of the gallbladder causes pain and spasms of the abdominal muscles which may make one feel nauseated.
Source:
Understanding Medical Surgical Nursing by Williams and Hopper page 742
The patient didn’t
complain of nausea or vomiting.
Mildly elevated
ABSENT Biliary obstruction causes suppression of bile flow,
The patient’s bilirubin was
Page | 45 serum
bilirubin
and regurgitation of conjugated bilirubin into the bloodstream.
Sources:
Harrison’s Principles of Internal Medicine, Tenth
Edition 1983 page 1829
not increased. associated with liver disease or muscle trauma.
Elevations may also be associated with a variety of conditions including myocardial infarction (heart attack), pancreatitis, bile duct obstruction and more.
Abnormalities of liver