[##]-year-old [male/female] with
abdominal pain [additional symptoms] with history and exam consistent with
likely symptomatic cholelithiasis.
Initial considerations in this
patient included symptomatic cholelithiasis, acute cholecystitis, cholangitis, choledocholithiasis,
pancreatitis, acute hepatitis, acute appendicitis, and gastroenteritis 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 symptoms 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]. [Patient
noted to have a negative pregnancy test in the ED making ectopic or other
pregnancy-related complications unlikely.
Gallbladder pathology was
considered a possible cause for this patient’s symptoms, and a [formal/bedside]
ultrasound of the right upper quadrant was obtained. The patient was
noted to have evidence of gallstones without findings consistent with acute
cholecystitis on ultrasound.
We discussed return precautions,
specifically worsening or persistent pain suggestive of cholecystitis, symptomatic
treatment, and follow up with primary care provider and surgery for further
evaluation and consideration of cholecystectomy, and the patient demonstrated understanding
and agreement with this plan.
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