In Partial Fulfillment of the Related Experience of N104 (Communicable Diseases) at Lipa City Colleges, Lipa City

Case Study of Calculous Cholecystitis

Sumbitted by: Abrogina, Jomarie Ann L. Cruz, John Rouke L. Magbuhat, Michael Angelo J. Mendoza, Rusiel M. Ocbian, Mark Danie M.l Reblando,Henna R. Reyes, Rita Mae L. Rosita, Princess G. Silva, Marthon O.

Date Submitted: March 18, 2013

TABLE OF CONTENTS
I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. INTRODUCTION DEMOGRAPHIC PROFILE HISTORY PHYSICAL ASSESSMENT NORMAL ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY DIAGNOSTIC PROCEDURE MEDICAL MANAGEMENT NURSING MANAGEMENT DRUG STUDY COURSE IN THE WARD/ PROGNOSIS NURSING CARE PLAN DISCHARGE PLAN

References

INTRODUCTION Gallbladder is one of the organs that we can live without. However, it doesnt mean it is of no use to the body. The gallbladder is a pear-shaped organ situated underneath the liver. Its function is to store bile and release it as needed for digestion. Bile emulsifies the fats in food, breaking them to small fragments so they can be further digested and absorbed in the small intestine. If the gallbladder is not working as it should, the digestion of fats can be seriously impaired.

One of the common gallbladder diseases is calculous cholecystitis. Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading to poor drainage of bile. Trapped bile can irritate and inflame the walls of the bladder, thus leading to inflammation. Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman & Brandt, 2006). It affects women more often than men and is more likely to occur at the age above . Fair complexion races are more prone to develop pigment stones. Moreover, people who are obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. In the United States, it is estimated that 6.3 million men and 14.2 million women aged 20 to74 had gallbladder disease (Everhart, Khare, Hill, Maurer, 2003). In the Philippines, an extrapolated prevalence of 5, 073, 040 people are affected by the disease (http://digestive.niddk.nih.gov/statistics). If the 6 Fs are present to the client s/he will be susceptible to acquire cholecystitis.
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Tenderness and guarding in the right upper quadrant are frequent signs. A palpable mass is present in one quarter of patients after 24 hours of symptoms but is rarely present early in the clinical course. Murphy's sign the arrest of inspiration while palpating the gallbladder during a deep breath may be useful, particularly when direct tenderness is absent (e.g., in a subsiding case). Fever and an elevation in the white-cell count are classically described in patients with acute cholecystitis, but either or both may be absent.

Acute

calculous

cholecystitis

is

diagnosed

radiologically

by

the

concomitant presence of thickening of the gallbladder wall (5 mm or greater) or direct tenderness when the probe is pushed against the gallbladder (Murphy's sign). Cholecystography detects gallstones the galbladders ability to refill, contracts, concentrates and empty. An iodide- containing contrast agent excreted by the liver and concentrated in the gallbladder is administered. If the gallstones are present, they appear as shadows on the x- ray film. Other Examination is, Endoscopic Retrograde Cholangiopancreatography ( ERCP) that permits

direct visualization of structures that could once be seen only during laparotomy. Multiple position changes are required during the procedure, beginning in the left semiprone position to pass the endiscope.

Treatments are

gallbladder surgery (cholecystectomy): A surgeon

removes the gallbladder, using either laparoscopy (several small cuts) or laparotomy (traditional open surgery with a larger incision). Antibiotics therapy is given because Infection may be present during cholecystitis. Non- Surgical

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Management is Extracorporeal Shockwave Lithotripsy which is used for non surgical fragmentation of gallstones. The word lithotripsy is derived from lithos, meaning stone, and tripsis, meaning rubbing or friction. This non- invasive procedure uses repeated shock waves directed at the gallstones in the gallbladder or common bile duct to fragment the stones. Surgical Managements are Laparoscopic Cholecystectomy and Traditional Cholecystectomy. In Traditional Cholecystectomy or Laparotomy, the gallbladder is removed through an abdominal incision(usually right subcostal) after the cystic duct and artery are ligated. Laparoscopic Cholecystectomy is performed through a small incision or puncture made through the abdominal wall in the umbilicus. The abdominal cavity is insufflated with carbon dioxide (PNEUMOPERITONEUM) to assist in inserting the laparoscope and to aid the surgeon in visualizing the abdominal structures. Though antibiotics dont typically cure cholecystitis, they can prevent an infection from spreading. In this case, The client undergone Laparascopic Cholecystectomy.

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PATIENTS DATA A. BIOGRAPHIC DATA

NAME ADDRESS AGE BIRTH DATE GENDER : Patient MRF : San Mateo, Rizal : 57 Years Old : November 26, 1956

: Female RELIGION RACE CITIZENSHIP STATUS OCCUPATION DATE OF ADMISSION ADMITTING DIAGNOSIS FINAL DIAGNOSIS

: Roman Catholic : Asian : Filipino : Single : Employee : February 8 2013 ( 11 AM) : RUQ Abdominal Pain : Acute Calculous Cholecystitis

Hospital: Vital Signs on Admission:

Veterans Memorial Medical Center (VMMC) BP: 130/80 mmHg PR: 90 bpm RR: 23 bpm T: 38.5 C W: 105 kg

Unit: Chief Complaint: Admitting Physician: Admitting Diagnosis: Final diagnosis Surgical procedure

3C- 324-5 Pain at right upper quadrant Dr. Walter Batucan Acute Cholelithiasis Calculous Cholecystitis Laparoscopic cholecystectomy

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B. CHIEFT COMPLAINT
The patient complains of RUQ abdominal pain which is happened for almost 4 days, She has had one episode of vomiting with the current attack. On physical examination, her temperature is 38.5C, and the heart rate is 95 beats per minute. She has tenderness and guarding in the right upper quadrant.

C. HISTORY OF PRESENT ILLNES According to her, 4 prior to admission, she felt slight pain at her right upper quadrant. She never take any medications, She still go to work ( morning Shift) thinking that it was brought about by hyperacidity and over fatigue.She was eating kwek- kwek then When the pain is progressing and felt that the pain at RUQ radiates at the right arm and upperback near the scapula decides her to be brought at the ER of Veterans Memorial Medical Center and seek for some medical explanation. The doctor said she have gallstone and she will be going to undergo a surgery which is Cholecystectomy. D. PAST HISTORY OF ILLNESS According to her, she was complete in different immunization offered at that time. She already had Mumps and Varicella; do not have any known food or drug allergies. She undergone Appendectomy way back 2007. Satisfied with care received at local hospital.She had also ectopic pregnancy way back 1980 (G1,P0)

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E. FAMILY HISTORY OF ILLNESS

Her father had Hypertension and died due to peptic ulcer: her Mother died with breast cancer. His Lolo who is a Spanish died due to Myocardial Infarction. F. Socioeconomic History The client lives alone in the house. She is an employee of a bowling center in the accounting and managerial position since it is a family owned business of her cousin for almost 21 years. She states that she earn above minimum wage and able to meet her needs and demands for daily living. G. Developmental History Describes childhood as a very happy time for her. Becomes excited and smiles as she relates stories of her childhood on the province of Rizal. States she was an average child and ran and played like all the others. Companion at home is her bestfriend. She is not able to get married since her had her ectopic pregnancy and a great failure in her lovelife. Became a accounting officer in the company she worked for almost 21 years. She states that mahirap magisa sa buhay, kung nakapagasawa lang sana ako.. mahihirapan na ako lalo ngayon galling ako sa opera. Does not voice financial concerns. States that she is not afraid of death since she accepted that he had undergone so many surgeries.

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H. Maternal History
She and her sibling were born via normal spontaneous delivery at home assisted by traditional komadronas, I. Nutritional History The client admits that she eats too much because of the stress brought by her work. She experienced to be on night shift thats why she skips breakfast and eat both lunch and breakfast in one big meal. She acclaims that he is party lover, that he drinks alcohol and tried to smoke when younger.

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DEFINITION OF COMPLETE DIAGNOSIS Complete Diagnosis: Calculous Cholecystitis

Calculous

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape and composition. Source: Boyer, M. (2006). Brunner and Suddarths Textbook of Medical Surgical Nursing, 11th ed., p. 1347. Lippincott Williams & Wilkins.

Calculus (pl. calculi) is also called stone; an abnormal stone formed in body tissues by accumulation of mineral salts. Calculi are usually found in the biliary and urinary tracts.

Source: http://medical-dictionary.thefreedictionary.com/calculi. Retrieved May 15, 2010. Calculi (stones) can be divided into two groupsrenal calculi and gallstones. The majority of gallstones are composed principally of cholesterol and other calcium salts.

Source: Iyengar, V. Elemental Analysis of Biological Systems: Biomedical, Environmental, Compositional and Methodological Aspects of Trace Elements, Vol. 1, p. 49.

Cholecystitis

Cholecystitis is the inflammation of the gallbladder. In more than 90% of the cases, gallstones are present.

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Source: White, L. Foundations of Nursing: Caring for the Whole Person, p. 832. Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation)

Source: Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers. Inflammation of the bladder which may be either acute or chronic. In an

acute cholecystitis, the blood flow to the gallbladder may become compromised which in turn will cause problems with the filling and emptying of the gallbladder. A stone may block the cystic duct which will result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. Chronic cholecystitis occurs when there have been recurrent episodes of blockage of cystic duct.

Source: Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill. Calculous Cholecystitis

Acute cholecystitis is inflammation of the gallbladder. There are two major types of acute cholecystitis calculous and acalculous. In calculous cholecystitis, gallstones obstruct the gallbladder outlet leading to poor drainage of bile. In physical exam, patients may exhibit Murphys sign right upper quadrant pain elicited by palpation under the right costal margin when the patient inspires. Source: Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.

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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.

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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.

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BILE The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin. 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.

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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: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1822 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

The patient is female.

Age (Forty and above)

PRESENT

Many of the bodys systems and protective mechanisms become less efficient with age. Body systems and processes become sluggish.
Sources: Harrisons Principles of Internal Medicine,

The patient is 57 years old.

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Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184

Ethnicity (Native American, Mexican American) (Asian) FAIR

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 in the Western countries
Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

The patient is Filipino And with trace of Spanish. She is predisposed to having pigment stones.

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Precipitating Factors Pregnancy FERTILE

Present/ Absent

Rationale

Justification

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.

Frequent 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 es/gallstns.cfm

No rapid weight loss was noted by the patient.

Obesity/ FAT

Present

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: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page

The patient is 105 kgs.

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1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm

Fasting

Present

Fasting decreases gallbladder movement, causing the bile to become overconcentrated with cholesterol, which can lead to gallstones. Source: http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

The patient fasts, specially when from night shift.

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Symptomatology Signs and Symptoms Present/ Absent Rationale Justification

Right upper quadrant pain (may radiate to right scapula, shoulder, or interscapular area) biliary colic

PRESENT

patient ducts The into connected to the gallbladder came Obstruction of will cause inflammation DMSF by increased complaining

produced

intraluminal pressure and of RUQ pain. distension gallbladder. Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1825 of the

Fever (low grade)

Present

nonspecific The response that is mediated was by endogenous pyrogens with Fever is a

patient febrile

released from host cells in temperature response to infectious or of 38.5. non-infections disorders. It may be brought about by prostaglandins released

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during inflammation. Source: Carol Mattson Porth (2005. Pathophysiology, Seventh edition page 205)

Murphy's sign (abrupt interruption of deep inspiration)

PRESENT

Classically Murphy's sign is tested for

The was

patient positive

during for the an abdominal examination; Murphys it is performed by asking the Sign. patient to breathe out and then gently placing the hand below the costal margin on the right side at the midclavicular line approximate location (the of

the gallbladder). The patient is then instructed to inspire (breathe during in). Normally, inspiration,

the abdominal contents are pushed downward as

the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder in moving in

is tender and, downward,

comes

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contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive. A

positive test also requires no pain on performing the maneuver on the patient's left hand side. Source: http://www.turnerwhite.com/pdf/hp_nov00_m urphy.pdf

Nausea and vomiting

PRESENT

Nausea

and

vomiting The

patient

sometimes occur with biliary didnt vomited colic. The inflammation of once before

the gallbladder causes pain admission and spasms of the

abdominal muscles which may make one feel

nauseated. Source: Understanding Surgical Medical by

Nursing

Williams and Hopper page 742

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Mildly elevated serum bilirubin

PRESENT

Biliary obstruction causes The patients suppression of bile flow, bilirubin was and regurgitation of ------------------

conjugated bilirubin into the -----------------bloodstream. Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1829 -----

Elevated SGPT and SGOT enzymes

PRESENT

SGOT (AST) and (ALT) is The patients an enzyme found mostly in lab the liver but also in the reveal heart, the muscles, the normal tests a level

kidneys, the pancreas and of SGPT and in red blood cells. High slightly elevations associated may with be increased liver SGOT

disease or muscle trauma. enzymes. Elevations may also be

associated with a variety of conditions including

myocardial infarction (heart attack), pancreatitis, bile

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duct obstruction and more. Abnormalities enzymes of liver

including

AST/SGOT and ALT/SGPT are indicative of problems such as Mirrizi syndrome, or a stone in the bile duct causing inflammation. Sources http://my.diabetovalens.com /apollo/sgot.asp infection/liver

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PATHOPHYSIOLOGY Precipitating Factors:

Predisposing Factors: Female Age 57 Race

Obesity fasting

Bile stagnates in the gallbladder

Cholesterol solutes precipitate as solid crystals Crystals clump together and form stones Gallstones

Gallbladder contracts after intake of fat to release bile Upon contraction, a stone is moved and becomes impacted on the cystic duct

CHOLELITHIASIS
Lumen is obstructed by stones Bile stasis

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Chemical reaction inside gallbladder triggers the release of inflammatory enzymes (Prostaglandins)

Fluids leak into gallbladder

Inflammation of the gallbladder

Edema

Increased intraluminal pressure and distention of the gallbladder

Biliary Colic (RUQ pain)

Constriction of blood vessels

Murphys Sign

ACUTE CHOLECYSTITIS

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DOCTORS ORDER Date 2/ 8/ 13 @ 11am Order Admit under the care of Dr. Batucan Rationale Admitted under the care of Dr. Batucan, a surgeon, for his specialties on surgical procedures (Laparoscopic cholecystectomy) Secure consent to care Consent is an agreement between client and health care provider to give proper quality care. It is also to protect the client from harmful procedures and the institution from law suits Low Salt, Low fat diet Doctors were not sure whether the gallstones are either cholesterol or pigment stones. Thus, this is done to prevent any further damage to the gallbladder. Monitor VSqShift and record Monitoring vital signs is important in order to note any unusualities and to refer these as follows. Labs: Done Done Remarks Done. Patient was placed in ROOM 345 Pre Op Ward Done

CBC

A complete blood count (CBC) is a series of tests used to evaluate the composition and

Done

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concentration of the cellular components of blood. It consists of the following tests: red blood cell (RBC) count, white blood cell (WBC) count, and platelet count; measurement of hemoglobin and mean red cell volume; classification of white blood cells (WBC differential); and calculation of hematocrit and red blood cell

Platelet

Platelet count is to determine the number of platelets; If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form (thrombosis), which may obstruct blood vessels.

Done

Urinalysis

It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances

Done

PNSS 1L @ 100cc/hr PNSS is an isotonic solution for 2 cycles to provide hydration since it

Done. IVF infusing well

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was found out that the specific gravity for urine is in the borderline (1.010). It is also to provide electrolytes, and as a medium for IVTT meds

at right metacarpal vein.

Meds:

Nalbuphine 10 mg IV now then prn for abdominal pain

Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation for relief of moderate to severe pain

Given

HNBB (Hyoscine NButyl Bromide) 20mg 1amp IVTT now

It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists causing smooth muscle relaxation indicated for her abdominal pain

Given

Omeprazole (Prilosec) 40 mg IV MHBR Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. This is also to prevent ascending infection that could be caused by possible rupture of the
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Done

gallbladder. Refer any unusualities: severe abdominal pain, vomiting 02/ 09/ 13 @8:30 Start Ciprofloxacin(Ciprob ay) 200 mg IV q8 ANST In order for the patient to be assessed and evaluated properly and be managed accordingly. Ciprofloxacin inhibits synthesis of bacterial cell wall causing cell death which acts Done. Result for skin test is negative. Done

as a perioperative prophylaxis Ciprofloxacin for surgical procedures. ANST or after negative skin test is to check whether the client is not allergic to the antibiotic. may be given to the patient.

For ultrasound tomorrow morning

This is done to visualize internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. This is also to know the condition of the gallbladder whether it ruptured or not.

Not able to comply. Patient had her ultrasound on February 10/ 13

For total bilirubin,

Bilirubin is elvated if hepatocytes are injured and cannot metabolize or excrete bilirubin

Done. Results are normal

Direct bilirubin,

Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts
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Indirect bilirubin

Increase in unconjugated bilirubin may be caused by hepatic disease, cholestasis, and hemolysis

SGPT (Serum glutamic pyruvic transaminase)

SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver function. Elevation of this may possibly mean liver problems AST (aspartate aminotransferase) or SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. It is also found in lesser amounts in other tissues. Elevated levels may be caused by liver or heart disease

Done. Patients SGPT results are normal

SGOT (Serum glutamic oxaloacetic transaminase)

Done. SGOT results are also slightly high

Schedule for laparoscopic cholecystectomy on February 10, 3 pm, Sunday Secure consent/AC

Lap Chole was to surgically remove the gallbladder with only a small incision.

Done. Surgery was done on 4/11/10 @ 4pm

Patient has the right to be consented in all procedures to

Done.

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be done, and for legal purposes. Anesthesia clearance is for the patient to be evaluated whether he/she is fit to undergo the operation. It is also for the anaesthesiologist to predict the operative risk and the appropriateness of the anaesthesia to be induced during operation. Inform OR For the OR to know that such case will be performed and to prepare the necessary instruments and room. This is also to coordinate availability of staff and surgeon Refer In order for the patient to be assessed and evaluated properly and be managed accordingly. May have ultrasound on Feb 10, 2013 This was to visualize internal organs, to capture their size, Done. Ultrasound Done Done

structure and any pathological result lesions with real time tomographic images. It is also to know whether the gallbladder has ruptured or not. retrieved on 02/10/13. Impression: Cholelithiasi s; Sonographic ally normal
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liver and pancreas

02/11/13 @ 8 Am

IVF TF: PNSS 1L @ KVO

PNSS is an isotonic solution for hydration and as a medium for IVTT meds; KVO was done since patients hydration was good. AC is to assess patients rate of survival and check for what anesthetics is right for the patient, making sure that the patient isnt allergic to the anesthetic

Done

Please facilitate AC

Done

For Lap Chole today 3 pm

This was to surgically remove the gallbladder with only a small incision. Patient can undergo laparoscopic cholecystectomy since gallbladder has not ruptured yet as seen on the ultrasound result.

Done.

For hematology. and Ultrasound tom

Blood tests are used to determine physiological and biochemical states, such as disease, mineral content, drug effectiveness, and organ function.

Done.

9:30pm

Pre-op orders:

NPO after light

NPO is to prevent peristalsis,

Done
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breakfast (8am)

aspiration and injury during surgery

Assess VS prior to OR

as baseline data and to detect Done any unusualities

General oral hygiene

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.

Done

IVF: D5NSS 1L @ 120cc/hr

Intravenous solutions with reduced saline concentrations typically have dextrose added to maintain a safe osmolality while providing less sodium chloride; to hydrate before surgery in preparation for disruption of homeostasis

Done

Meds:

Diazepam 10mg 1 tab 2am

Potentiates the effects of GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; it is also used as adjunct to General anesthesia

Given

Given
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Ranitidine 150mg 1tab 2am

Inhibits basal gastric acid secretion and gastric acid secretion; patient was placed on NPO

Vitamin K

For the liver to activate clotting factors such as prothrombin, proconvertin, thromboplasstin, and stuart factor.

Given

02/12/13 1:30pm

NPO

NPO is to prevent peristalsis, aspiration and injury to the GI tract during surgery.

Done

Post op orders:

To RR then to room

Patient must first be stabilized Done before transfer to the ward; RRis a place with complete gadgets and staff for emergency purposes after post op.

NPO for 4 hrs then may have SD Patient not yet fully conscious due to anesthetics, thus this is to prevent aspiration. Monitor VS q15 until stable then q30 for 2hrs then q2 Monitoring vital signs is to detect any unusualities after the operation. Meds:
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Done

Done

Etoricoxib 120mg PO 12mn

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Given

Tramadol 100mg 1tab 12mn

Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Given

Inhibits synthesis of bacterial cell wall causing Cefuroxime 500 md 1 cell death; this was tab mg PO TID indicated due to possible intra abdominal infections O2 inhalation @ 4pm until fully awake This ensures optimum oxygenation of cells gearing towards achieving balance or homeostasis. Also this was for optimum respiratory level; prevents lung collapse. MHBR Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. Deep breathing exercises for 15mins Post op exercise is indicated To prevent lung collapse and
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Given

Done

Done

Done

TID

to eliminate anesthetic gases introduced to the body

02/13/13 11:15am

May have DAT

Patient may eat anything as long as it cant harm her current condition

Done.

Continue meds

For the patient to complete the medication regimen and for continuity of care

Done

Wound care

Daily routine wound care is indicated in order to promote healing and/or prevent infection

Done

02/14/13 11:30 AM Continue present management

May Remove Foley Catheter Now After Bladder Training 02/15/13 9:00am MGH Patient may go home after the doctor decides if unusualities are absent Home meds:

Removed at 1 pm

Done

Etoricoxib 90mg PO BID

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Done. Patient was informed

Tramadol 100mg

Half life is 5-7hrs

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tab PO BID

Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Cefuroxime 500 mg Po

Inhibits synthesis of bacterial cell wall causing cell death

C/D IVF

Terminate IVF when IVF is about 50cc

IVF discontinued Patient to come back at 5/18/10

ff. up check at 5/18/10

Follow up check up is for the patient to be assessed and evaluated properly and be managed accordingly.

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DIAGNOSTIC EXAM CBC a determination of red and white blood cells per cubic millimeter of blood. It helps health professional check any symptoms such as weakness, fatigue, or bruising. It also helps diagnose conditions such as anemia, infection and other disorders May 8, 2010 Test Hemoglobin Normal Result Remark Rationale Values 115.0- 137.0 Normal Hemoglobin carries 155.0 oxygen to and removes carbon dioxide from red blood cells. It measures total amount of hemoglobin in the blood Hematocrit 0.360.52 0.42 Normal Hematocrit measures the percentage of red blood cells in the total blood volume RBC 4.2-6.1 4.47 Normal Measures the number o RBCs per cubic millimeter Within normal range The patient may feel discomfort when blood is Within normal range Interpretation Within normal range Nursing Responsibilities There is very little risk associated with taking blood from a vein in the arm, although there is a slight risk of infection anytime the skin is broken. Strict asepsis should be observed

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of the whole blood. WBC 5.010.0 14.1 High Determines the number of circulating WBCs per cubic millimeter of the whole blood. Elevated levels acute infections tuberculosis, pneumonia, meningitis, tonsillitis, appendicitis, colitis, etc. Neutrophil 55-75 74 Normal Phagocytes engulfing bacteria and cellular debris. It prevents or limits bacterial infections. Lymphocytes 20-35 21 Normal Cells present in the blood and lymphatic tissue that provide the main means of immunity for the body. There are three types of lymphocytes: the natural Within normal range Within normal levels.

drawn

from

vein.

Bruising may occur at

may be caused by the puncture site, or the person may feel dizzy or faint. Pressure should be applied to the puncture site until the bleeding stops to reduce bruising. Warm packs can also be placed over the puncture vsite discomfort to relieve

Instruct patient in dietary sources of iron such as red meat, organ meats, clean green vegetable and fortified grains

Protect the patient from

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killer (NK), thymus-derived lymphocytes (T cells), and bone marrow-derived lymphocytes (B cells). NK cells are found in the blood, red bone marrow, lymph nodes and spleen and are able to destroy many kinds of infected body cells and tumor cells. The T cells and B cells are involved in specific immune responses. Monocytes 2-10 4 Normal This type of granular leukocyte functions in the ingestion of bacteria and other foreign particles Eosinophil 1-8 1 Normal Functions in allergic responses and in resisting infections. Eosinophils Within normal range Within normal range

potential sources of infection, monitor for signs of infection. Provide soft, bland diet high in protein, vitamins, and calories. Meticulous hand washing and strict asepsis are mandatory

Institute isolation

protective measures

immediately if there is neutrophil disorder. Also instruct the patient to observe aseptic

technique and to take caution most especially if immunocompromised. Inflammatory responses involve more than one

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mount on attack against parasitic invaders by attacking to their bodies and discharging toxic molecules from their cytoplasmic granules. Platelet 150.0400.0 278 Normal A test that direct count of platelets in whole blood. Platelets number from 100,000-500,000 per cubic millimeter and are important in triggering the sequence of events that leads to the formation of blood clots. Within normal range

body

system.

Monitor

the patient for worsening of the inflammatory particularly

condition, respiratory

compromised.

Encourage patient to rest between activities. Encourage patient to plan ahead and save energy for the most important activities. Encourage patient to void or stop activities that make short of breath or make heart beat faster.

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Encourage patient to Eat a diet with adequate protein and vitamins. Drink plenty of noncaffeinated and nonalcoholic fluids.

Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances May 8, 2010 TEST Glucose RESULT Negative NORMAL <50mg/dL CLINICAL SIGNIFICANCE Glucose is the type of sugar found in blood. Normally there is very little or no glucose in urine. When the blood sugar level is very high, as in uncontrolled diabetes. Glucose can also be found in Wash hands to make sure they are clean NURSING RESPONSIBILITIES Advise Patient to:

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urine when the kidneys are damaged or diseased. Protein Negative <30mg/dL Protein is normally not found in the urine. Fever, hard exercise, pregnancy, and some diseases, especially kidney disease, may cause protein to be in the urine. Bilirubin Negative <1mg/dL This is a substance formed by the breakdown of red blood cells. If it is present, it often means the liver is damaged or that the flow of bile from the gallbladder is blocked.

before collecting the urine. If the collection cup has a lid, remove it carefully and set it down with the inner surface up. Do not touch the inside of the cup with your fingers. Clean the area around your genitals. Begin urinating into the toilet or urinal. Finish urinating into the toilet or urinal. Carefully replace and tighten the lid on the
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cup then return it to the lab. After the urine has flowed for several seconds, place the collection cup into the urine stream and collect "midstream" urine without stopping your flow of urine. Do not touch the rim of the cup to your genital area. Do not get toilet paper, pubic hair, stool (feces), menstrual blood, or anything else in the urine sample.

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pH

4.5-8

Urine pH is used to classify urine as either a dilute acid or base solution. The lower the pH, the greater the acidity of a solution; the higher the pH, the greater the alkalinity. The glomerular filtrate of blood is usually acidified by the kidneys from a pH of approximately 7.4 to a pH of about 6 in the urine

Blood

Negative

<510RBC/mL

Red blood cells in the urine may be caused by kidney or bladder injury, kidney stones, a urinary tract infection (UTI), inflammation of the kidneys (glomerulonephritis), a kidney or bladder tumor, or systemic lupus erythematosus (SLE).

Leukocytes

25

<25WBC/m L

Leukocyte esterase shows leukocytes in the urine. WBCs in the urine may mean a UTI is present. Urine is normally clear. Bacteria, blood, sperm, crystals, or mucus can make urine look cloudy.

Clarity

Clear

Clear

Specific gravity

1.010

1.010-1.030

This checks the amount of substances in the urine. It also shows how well the kidneys balance the amount of water in urine. The higher the specific

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gravity, the more solid material is in the urine. Color Yellow Pale to dark yellow Many things affect urine color, including fluid balance, diet, medicines, and diseases. How dark or light the color is tells you how much water is in it. Vitamin B supplements can turn urine bright yellow. Some medicines, blackberries, beets, rhubarb, or blood in the urine can turn urine red-brown.

Blood Chemistry - A number of tests performed on blood serum (liquid portion of the blood). It determines certain enzymes that may be present (including lactic dehydrogenase [LDH], certain kinase [CK], aspartate aminotransferase [AST], and alanine aminotransferas [ALT]), serum glucose, hormones such as thyroid hormone and other substances such as cholesterol and triglycerides. These tests provide valuable diagnostic cues.May 9, 2010

TEST Total Bilirubin

RESULT 8.3

REFERENCE 2.0 21.0

REMARK Normal

RATIONALE It occurs when bilirubin production exceeds the liver's excretory capacity. This may occur because (1) too much bilirubin is being produced, (2) hepatocytes are injured and cannot metabolize or excrete bilirubin, or (3) the biliary tract is obstructed blocking the flow of
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conjugated bilirubin into the intestine Direct Bilirubin 0.9 0.0 3.4 Normal Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts Inderct Bilirubin 7.4 2.0 17.0 Normal Increase in unconjugated bilirubin may be caused by hepatic disease, cholestasis, and hemolysis SGPT .9 0.0 34.0 Normal SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver disease. SGOT 55.6 0.0 31.0 High SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. Elevated levels may be caused by liver or heart disease

Pro- Thrombin

111.3

12- 16 secs

LOW

Prolonged by deficiency of factors I, II,V, VII, and X, fat malabsorption,severe liver disease, coumaDin anticoagulant therapy. Present cbc shows normal Prothrombin time

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Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. Ultrasound has been used by sonographers to image the human body for at least 50 years and has become one of the most widely used diagnostic tools in modern medicine.

12/28/10 Impression:

Veterans Memorial Medical Center

obstructive cholelithiasis Ultrasonically normal liver, intrahepatic ducts, pancreas, spleen, aorta, paraaortic areas, kidneys and urinary bladder

Nursing Responsibilities: Explain the procedure and purpose of the test Provide a gown without snaps, and ask the patient to remove all jewelry Take ultrasound if the patients bladder is fluid filled for better results

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PROCEDURAL REPORT

Procedural Report A. Definition of Laparoscopic Cholecystectomy The surgery to remove the gallbladder is called a cholecystectomy. The gallbladder is removed through a 5 to 8 inch long incision, or cut, in the abdomen. The cut is made just below the ribs on the right side and goes to just below the waist. This is called open cholecystectomy. A less invasive way to remove the gallbladder is called laparoscopic cholecystectomy. This surgery uses a laparoscope (an instrument used to see the inside of your body) to remove the gallbladder. It is performed through several small incisions rather than through one large incision. A laparoscope is a small, thin tube that is put into your body through a tiny cut made just below the navel. The surgeon can then see the gallbladder on a television screen and do the surgery with tools inserted in three other small cuts made in the right upper part of the abdomen. The gallbladder is then taken out through one of the incisions. B. Procedure

1. Placed on supine position, reverse trendelenburg 2. Administration of General Endotracheal Anesthesia (GETA) 3. Skin over surgical site is cleansed with antiseptic solution 4. Placement of drapes.

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5. Three to four small incisions is made in the abdomen.

Carbon dioxide gas is introduced into the abdomen to the

inflate

abdominal cavity so that the gallbladder and surrounding

organs can be more easily visualized. 6. The laparoscope is inserted through one of the incisions (usually at the incision below the umbilicus) and instruments will be inserted through the other incisions to remove the gallbladder. 7. When the procedure is completed, the laparoscope is removed. 8. The gallbladder is sent to the lab for examination 9. The skin incisions are closed with stitches or surgical staples. 10. A sterile bandage/dressing or adhesive strips is applied.

C. Nursing Responsibilities Preoperative Phase o Secure the informed consent for legal purposes and take note of the following things: 1. The surgeon must provide a clear and simple explanation of the surgical procedure. 2. The nurse may witness the patients signature. 3. If the patient needs additional information about the procedure, nurse notifies the surgeon.

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4. The nurse ascertains that the consent form has been signed before administering psychoactive drugs. 5. No patient should be urged or coerced to sign an operative permit. 6. Refusing to undergo a surgical procedure is a persons legal right and privilege. o Assess for drug and alcohol abuse. Persons with history of chronic alcoholism often suffer from malnutrition and other systemic problems that increase the surgical risk. o Assess the respiratory status. The goal for potential surgical patients is optimal respiratory function. o Assess the cardiovascular status. The goal in preparing any patient for surgery is to ensure a well functioning cardiovascular system to meet the oxygen, fluid and nutritional needs. o Assess the hepatic and renal functioning. Presurgical goal is optimal function of the liver and urinary system to enhance removal of medications. o Assess the immune functioning. An important function of the preoperative assessment is to determine the existence of allergies. o Assess for the previous medication use. A medication history is obtained from each patient because of the possibility of drug interactions o Make nursing diagnoses, and prepare nursing care plans to address patients needs o Teach deep-breathing, coughing and incentive Spiro meter to aid the patient post operatively o Encourage mobility and active body movement to avoid complications

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o Teach cognitive coping strategies such as imagery, distraction and optimistic self-recitation to reduce fear and anxiety o Explain the activities that may occur inside the operating room to reduce anxiety o Inform the patient on the following to impart knowledge on the part of the patient and to avoid delay in surgery due to noncompliance: Scheduled date and time of the surgery and where to report What to bring such as insurance card, list of medications and allergies What to leave at home such as jewelry, watch, medications and contact lenses What to wear which is loose-fitting, comfortable clothes and flat shoes take nothing by mouth for six to 12 hours before the surgery. o Acquire and document patients vital signs for baseline data and maintain the preoperative record o Transport the patient to the presurgical area to prepare the patient for surgery o Attend to the family needs to reduce the anxiety felt by the family o Make sure that preoperative checklist which contains the following is accomplished: Lab exam results in OR services form accomplished Patient is scheduled in OR Anesthesiologist informed Medicines in Blood Typed and Matched Field of Operation prepared
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 Intraoperative phase

Sponged or bathed Diet instruction given Enema given Make-up and nail polish removed Jewelry removed Oral hygiene given Patient changed into patients gown Indwelling catheter inserted Pre-op meds given Medicine for OR in

o Position the patient: The patient is in a supine position reverse trendelenburg. o Skin preparation o Circulating nurse: Manages the operating room Protects patients safety and health by monitoring the activities of the surgical team Checks and verifies the consent form Ensures fire safety precautions, cleanliness, proper temperature, humidity and lighting of the operating room Monitors safe functioning of the equipments Coordinates with the surgical/ perioperative team and monitors aseptic practices Documents operating room surgical activities
Count all needles, sponges and instruments together with

the scrub nurse o For the scrub nurse: Setting up sterile tables
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Assisting the surgeon and assistant surgeon, taking care of tissue specimens Count all needles, sponges and instruments together with the circulating nurse

Postoperative Phase o Assess patient : appraise air exchanges status & note skin color; verify & identify operative status & surgeon performed; assess neurological status (LOC) o Perform safety checks good body alignment, side rails and maintain patent airway and cardiovascular stability o Medication Analgesics are administered as prescribed for pain. Antibiotics are administered to prevent infection.

o Surgical dressing is assessed periodically and reinforced when necessary. o HEALTH TEACHINGS Inform the patient about the importance of complying with

the prescribed medication. Emphasize the proper dosage of the medications taken. Educate the client about the importance of proper

nutrition. Encourage the client to have the prescribed diet for her

condition. Encourage to have early ambulation in order to promote

circulation and wound healing. Instruct to do splinting while performing deep breathing

exercises to minimize pain.

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DISCHARGE PLAN (M.E.T.H.O.D.)

I.

MEDICATION 1. Take medications as ordered. 2. Inform the patient to take medications on time or as directed for the full course of therapy even if feeling better. 3. Inform the client about the adverse effects and possible side effects of the medications. 4. Inform the client about the importance of taking prescribed medications and the consequences of not following the treatment regimen. 5. Encourage the patient to report or inform the health team if any of these side effects occur. Inform and explain to the client that other drugs that he is taking will probably have effects with the medication given. Moreover, emphasize the right time interval of these drugs to maximize its effects and avoid further complications. 6. Provide information for better understanding regarding therapeutic regimen. 7. Home medications are: Etoricoxib 90mg PO BID: 8 am, 6 pm Tramadol 100mg tab PO BID: 8am, 6 pm Cefuroxime 500 mg PO BID: 8am, 6pm (After meals)

II.

EXERCISE 1. Promote regular light exercise and exercise as tolerated. 2. Encourage exercise in lower and upper extremities to promote good circulation. 3. Inform patient about proper exercise regimen to avoid injury. 4. Alternate rest periods with activity. 5. Encourage walking exercise.

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III.

TREATMENT 1. Instruct the patient to continue drug therapy as ordered. 2. Inform the patient as well as family the dangers of non compliance to treatment regimen. 3. Discuss to the patient the complications and other problems that might arise from the condition. 4. Inform the patient to exercise and do breathing exercises. 5. Instruct the patient to report to the health team promptly about any changes on health condition. 6. Encourage patient to strictly comply with the doctors orders, especially in taking prescribed medications. 7. Encourage the patient to have followed up visitations to the physician after discharge.

IV.

HEALTH TEACHINGS 1. Encourage patient to avoid strenuous activities. 2. Improving nutritional intake; meal planning is implemented with High fiber moderate calorie, low fat and low salt as the primary goal. 3. Encourage to balance diet and intake of nutritious food such as vegetables and lean meat, avoiding high fat foods. 4. Check with healthcare provider to evaluate progress of the condition. 5. Encourage to have adequate hydration. Water is the best source of fluid that is needed by the body to maintain its function. 6. Instruct to avoid alcoholic beverages due to a compromised hepatic system. 7. Encourage to have a restful and quiet atmosphere at home. 8. Encourage patient to use relaxation skills when in pain. 9. Encourage patient to seek emotional and social support especially to family and friends to promote strength and comfort. 10. Check the condition with a healthcare provider to evaluate progress of the condition.
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V.

OUTPATIENT 1. Remind patient on the arrangements to be made with the physician for follow-up checkups. 2. Follow-up check up regularly in order to monitor and properly manage patients illness. 3. Inform to continue medication as ordered. 4. Instruct to have a follow-up check up or refer to the physician if the patient is uncomfortable. 5. Instruct the patient and significant others to report for any irregularities.

VI.

DIET 1. The diet recommended for the client is High fiber moderate calorie, low fat and low salt 2. Encourage patient to increase nutritious foods intake by eating fresh fruits and vegetables, whole grain products, and lean meat. 3. Recommend to eat 5 or more servings of vegetables and fruits each day. 4. Encourage to choose whole grain foods instead of white flour and sugars. 5. Advise to try to limit meats that are high in fat and cut back on processed meats like hot dogs and bacon. 6. Inform patient to avoid food such as salted, cured, smoked, or canned meat. 7. Increase oral fluid intake. Hydration is needed by the body to transport nutrients needed by the body. 8. Instruct to avoid drinking of alcoholic beverages as much as possible. 9. Encourage not to forget to get some type of light exercise because the combination of good diet and regular exercise will help in the maintenance of healthy weight and the feeling of more energetic.

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REFERENCES Berman, A. et. al. (2008) Kozier & Erbs Fundamental of Nursing Concepts, Process and Practice 8th Edition. Pearson Prentice Hall, volume Two, Chapter 42, stress and coping Boyer, M. (2006). Brunner and Suddarths Textbook of Medical-Surgical Nursing, 11th ed. Carol Mattson Porth (2005). Pathophysiology, Seventh edition. Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers. Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill. Everhart, JE, Khare, M, Hill, M, Maurer, KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117:632. Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated. Harrisons Principles of Internal Medicine, Tenth Edition 1983. Iyengar, V. Elemental Analysis and of Biological Systems: Aspects Biomedical, of Trace

Environmental,

Compositional

Methodological

Elements, Vol. 1, p. 49. Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 MIMS 113th edition 2007 Talamini, M. (2006). Advanced Therapy in Minimally Invasive Surgery, p. 179. USA: Decker Inc. Taylor, Lillis, LeMone and Lynn (2008),Fundamentals of Nursing: The Art and Science of Nursing Care, 6th edition. Understanding Medical Surgical Nursing by Williams and Hopper page 742 White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.
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 http://arcoxia-side-effects.com/ http://digestive.niddk.nih.gov/statistics http://home.intekom.com/pharm/quatrom/q-hyosc.html http://medical-dictionary.thefreedictionary.com/calculi http://www.diabetesmonitor.com/learning-center/gallstones.htm http://www.drugs.com/arcoxia.html http://www.drugs.com/enc/vitamin-k.html http://www.drugs.com/mtm/ampicillin-and-sulbactam.html http://www.drugs.com/ultram.html http://www.healthline.com/goldcontent/ranitidine http://www.learningplaceonline.com/stages/organize/Erikson.htm http://www.medicinenet.com/hyoscine_butylbromide-oral/page2.htm http://www.medicinenet.com/tramadol/article.htm http://www.netdoctor.co.uk/medicines/100000395.html http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-vitamink.html http://www.pfizer.com/files/products/uspi_unasyn.pdf http://www.rxlist.com/unasyn-drug.htm http://www.turner-white.com/pdf/hp_nov00_murphy.pdf http://www.webmd.com/drugs/drug-11276-Ultram+Oral.aspx www.drugs.com/valium.html www.medicinenet.com/diazepam/article.htm www.medicinenet.com/ranitidine/article.htm www.revolutionhealth.com/drugs-treatments/cefoxitin www.rxlist.com/zantac-

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