MDM - Acute Cholecystitis (Male)

[##]-year-old male with abdominal pain [additional symptoms] with history and exam consistent with likely acute cholecystitis [additional].

Initial considerations in this patient included acute cholecystitis, cholangitis, symptomatic cholelithiasis, choledocholithiasis, pancreatitis, acute hepatitis, acute appendicitis, gastroenteritis, ureteral stone, pyelonephritis, and bowel obstructions among others.

Patient presented with right upper quadrant pain with associated [nausea/vomiting/jaundice] suggestive of gallbladder pathology.  Patient noted to have [no] known history of gallstones.  Patient reported duration of pain of [##] hours at time of ED evaluation.  The patient was noted to have [no evidence of peritonitis/rebound tenderness and guarding] and a [positive/negative] Murphy sign on abdominal exam in the ED.  Labs were obtained to include a CBC, liver function tests [additional] and were [unremarkable/notable for leukocytosis and left shift/elevated, bilirubin/elevated transaminases].

Gallbladder pathology including acute cholecystitis was considered [likely/highly likely] based on [history and exam/labs], and [a formal/bedside ultrasound of the right upper quadrant was obtained/Surgery was consulted for further evaluation].  The patient was noted to have findings consistent with acute cholecystitis on [ultrasound including characteristic shadowing of stones, gallbladder wall thickening (>3 mm), pericholecystic fluid, and a sonographic Murphy’s sign/exam by Dr. NAME of Surgery].  Additional imaging was [not felt to be indicated at this time after discussion with Surgery/recommended by Surgery to include a HIDA scan/ERCP/MRCP].

We discussed the diagnosis of acute cholecystitis and plan for admission for further management to include possible surgical intervention with the patient, who demonstrated understanding and agreement.  We also discussed the case with Dr. [Name] of General Surgery who agreed with the diagnosis and need for admission to the [general floor/pre-operative unit/OR] for further management.

Patient noted to have [no] evidence of significant systemic infectious symptoms [including fever/etc.] with [initiation of antibiotics in the ED/holding off on antibiotics until OR/at this time].

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