After orienting him to the room, you perform your physical assessment. The findings are as follows: He is awake, alert, and oriented × 3, and he moves all extremities well. He is restless, constantly shifting his position, and complains of fatigue. Breath sounds are clear to auscultation. Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm. Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. He reports having light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. skin and sclera are jaundiced.
Admission vital signs are blood pressure 164/100, pulse of 132 beats/min, respiration 26 breaths/min, temperature of 100° F (37.8° C), spo2 96% on 2 L of oxygen by nasal cannula.
Preoperative Laboratory Test Results
· WBC 11,900/mm3
· Hgb 14.3 g/dL
· Hct 43%
· Platelets 250,000/mm3
· ALT 200 units/L
· AST 260 units/L
· ALP 450 units/L
· Total bilirubin 4.8 mg/dL
· PT/INR 11.5 sec/1.0
· Amylase 50 units/L
· Lipase 23 units/L
· Urinalysis Negative
1. What organs are located in the RUQ of the abdomen? (Start thinking about what organ is involved based on his chief complaint)
2. What does a positive Murphy’s sign indicate when a health care provider performs deep palpation?
3. Which lab results are abnormal, and what do they reflect?
4. Which other data in the assessment are consistent with common bile duct obstruction?
5. Explain the pathophysiologic changes that can cause these signs and symptoms associated with common bile duct obstruction.
A. Clay colored stools
B. Dark urine
E. Pain with fatty food intake
The patient’s abdominal ultrasound reveals several stones in the common bile duct and gallbladder. He is admitted to the medical-surgical unit and placed on nothing by mouth (NPO) status and scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) that afternoon.