Thursday, January 12, 2012

A Clinic Nurse

I was working in my usual clinic seeing patients who had various diagnosis’ related to their liver, generally some sort of hepatitis (inflammation of the liver).  As I exited one of the patient’s rooms, Meg, one of the clinic RNs asked me to come and see her after I had finished seeing all of my scheduled patients. 
I told Meg I would come and find her in about two hours, after my clinic was finished.  She told me that would be fine.
After I finished my morning clinic, I went to find Meg.  I enjoyed working around Meg, she was a very good clinic nurse and went out of her way to help the other nurses.  I also enjoyed seeing her newest pictures of her newborn baby boy who was about 9 weeks old.  She had just recently returned from her maternity leave.  She was so happy to have finally been able to have a child at the age of 35. 
“Meg, I’m free of my clinic patients now.  What did you need?”
“You’re very good at what you do, so I need you to see me.  I don’t want to go and see my OB/Gyn about this, he’s across town.  I’m having pain right here.”  With that she put her hand over her upper right quadrant of her abdomen. 
“Okay, well then let’s go into one of the empty exam rooms and I’ll take a look.”
Meg walked somewhat gingerly into one of the empty exam rooms and I followed behind her.  I closed the exam door and sat down on the exam room stool. 
“Okay, what’s going on?”
“I started having discomfort and now it just hurts over my upper right quardrant.  It started to bother me about a week ago, I noticed that the pain would start up after I would eat some fatty foods.  But now this morning the pain hasn’t gone away and it just hurts constantly.  I don’t want to eat anything, I don’t have any appetitie since this morning, but I’m trying to stay hydrated. “
“Okay, are you having any fevers, vomiting or diarrhea?”
“No, none of those, although I might have felt a little warm this morning.”
“Alright, well what medications are you on right now?”
“I’m still taking my prenatal vitamin and a calcium supplement.”
“Okay, what about medication allergies?”
“Anything in your family history?”
“Both of my parents are still alive, my dad has some hypertension, my mom has type 2 diabetes.  That’s it.”
“And your medical history is your previous pregnancy, anything else?”
“No, nothing.  I’m just trying to lose this pregnancy weight I put on, but that’s it.” 
“Okay, well then let me exam you and then I’ll call and try to get your abdominal ultrasound scheduled for this afternoon.”

The gallbladder lies somewhat hidden up underneath the liver on the right side of the abdomen, just below the lower right rib cage.  It’s purpose is to excrete bile into the digestive system when you eat fatty foods.  Bile breaks down the fat and allows your system to absorp it for energy use. 

When people have problems with their gallbladder they can present with pain in their upper right hand quadrant of their abdomen, nausea, vomiting, fevers, sometimes a fast heartbeat, sometimes a positive ‘Murphy’s sign’ which means that they have pain elicited when you press into the midline of the right upper abdominal quadrant while the patient is taking a deep breath.

Patients can also give a history of having pain about one hour after eating a fatty meal.  The gallbladder is being asked to excrete bile and this generally elicits the pain, either from the gallbladder going into spasms or from a gallbladder stone becoming trapped in the bile ducts. 

I did my usual physical exam that I do on new patients, by listening to her chest, heart sounds, had her lay down so that I could do a thorough abdominal exam and then did a quick peripheral exam of her arms and legs.  Meg had a definite ‘Murphy’s sign’ with tenderness to palpation over the midline of her right upper abdominal area.  She was also a little tender over her epigastric area.  She also had some mild rebound tenderness over her right upper abdominal area.  All of this along with her history told me that she most likely had acute cholecystitis, or an inflammed gallbladder that needed to be surgically removed. 
I let Meg sit back up on the exam table and then told her, “Meg I’m going to go call the ultrasound tech downstairs and try to get you into to have an ultrasound done ASAP.  I’ll be right back, hang tight.”
A few minutes later I walked back into the exam room and told Meg that I had been able to get her scheduled as an overbook in ultrasound within the hour.
“Meanwhile, Meg, I need you to get some blood work drawn, I need a complete blood count, INR, and liver function tests done.  So here is your lab slip, I’ll follow up on these later.  I’ll also call the radiologist and ask him to read your ultrasound after it’s done.  If it shows what I think it will, then I’ll call the surgical service for you and have them see you right away.  You’ll most likely need to have a laproscopic cholecystectomy done.  And the surgical service likes to do these sooner rather than later so that your gallbladder doesn’t become infected and present complications.”
“Thanks, Sharon.  I really appreciate it.”
“Make sure to stay hydrated and don’t eat anything, I’ll call you after I talk to the radiologist.”

Risk factors for having problems with your gallbladder include:
--recent weight loss
--certain drugs
--increased trigylcerides (a part of the lipid panel)

Typical work-up for the gallbladder includes:
--abdominal ultrasound which can show gallbladder wall thickening or swelling
--HIDA scan which is done if the ultrasound is negative, this is a test where dye is injected into the patient’s bloodstream and then as the dye is excreted through the liver into the gallbladder, if the gallbladder is not visualized then this is a positive test
--rarely do we have to order a MR cholangiography (magnetic resonance testing) or a CT scan of the abdomen
--blood work is ordered to ascertain whether the patient is becoming infected from the gallbladder or whether there are other complications occuring such as involvement of the bile ducts with an occluding gallstone, etc.

Later that afternoon, I placed a call to the radiologist reading ultrasounds.  I told him what was going on with Meg and he pulled up her ultrasound. 
After he quickly looked at Meg’s ultrasound, he said, “Sharon, you can calll Meg and tell her she needs to see the surgeon, she’s got a positive ‘Murphy’s sign’ on her ultrasound and several large gallstones in her gallbladder.”
I told the radiologist, thanks for his help and put in a call to Meg.
“Meg, your ultrasound is positive for a problem with your gallbladder, where do you want to have your surgery done?”
“I’ll have it done here, that way my insurance will pay 100% of the costs, so you can refer me to the surgical clinic on the first floor.”
“Alright, well then let me page them and see whether they can get you in tomorrow to be seen.  I’ll call you back.”
I hung up the phone and paged the surgical service on call.  Dr. Brooks returned the call, he was a third year surgical resident.  I explained to him what was going on with Meg and her ultrasound results.  He told me that he would call me back in about 10 minutes as soon as he ran the case by the attending. 
Twenty minutes later, Dr. Brooks was back on the phone with me. 
“Sharon, Dr. Kessler, my attending took a look at Meg’s ultrasound report and he says based on it being a positive study, we don’t need to see her in clinic.  We also saw her labwork that was done.  We can just do her as a direct admit through day surgery.  Call her back and tell her that we have her scheduled on Friday for her lap cholecystectomy, she needs to be in day surgery clinic checking in at 6 am.  She should be able to go home Saturday morning.  Anesthesia can see her in day surgery clinic prior to the procedure and one of our surgical interns can do her pre-op history and physical then.  Make sure she doesn’t eat or drink anything from midnight on prior to her scheduled surgery.  Any questions?”
“Nope, I think that covers it, thanks much for your help.  I’ll call Meg and tell her what to expect.”
I placed a call to Meg who was still in clinic trying to get some work done.  I told her what the surgical resident had said to me and relayed the pre-op instructions. 

Treatment for acutely inflammed gallbladders (cholecystitis) is for the patient to have either a laproscopic cholecystectomy (removal of the gallbladder through a small opening in the abdominal wall) or an open cholecystectomy where the patient has about a 4-6” incision over their right upper abdomen.  Generally the surgical services will try to do a laproscopic cholecystectomy if at all possible.  This leads to a shorter recovery period. 

IV antibiotics can also be used just prior to and after the surgery if the surgical service feels they are removing an infected gallbladder.  But not all patients need antibiotics, seeing that less than half (46%)  of patients with acute cholecystitis have a positive surgical culture. 

“Thanks for your help, Sharon.  I’m still nauseated, so I don’t think I’m going to be eating anything anyway between now and 36 hours from now on Friday morning.  I’ll go let Pat (her nursing supervisor) know that I’ll be out for a few weeks.  I’ll be glad to get this taken care of, it kind of puts a wrench in my wanting to do anything. “
“Alright, well if you need anything for your nausea, let me know, you can take some Tylenol for the discomfort, that won’t bother your clotting factors for surgery.”
The next day in clinic, Meg wasn’t feeling too perky, she remained nauseated, but didn’t want to take anything for it.  Around noon, I noticed that Meg had gone home for the rest of the day.  Friday afternoon, Pat came and found me and told me that Meg had her lap cholecystectomy that morning and she had gone up to see her in the recovery room.  She said Meg was comfortable and her nausea was finally gone.  Dr. Brooks had come by and told her that everything had gone very well and they were planning on discharging her home in the morning. 
Four weeks later, Meg was back at work having fully recovered. 

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