[##]-year-old female 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, ovarian cyst, ovarian torsion, ectopic pregnancy and other
pregnancy-related complications, 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]. Patient noted to have a negative pregnancy
test in the ED making ectopic or other pregnancy-related complications
unlikely.
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.
