46 y/o F complains of abdominal pain x1 day

History

• Onset: 1 day ago
• Location: epigastric/RUQ
• Character: sharp
• Alleviating/exacerbating factors: took advil without improvement, worse after eating
• Radiation: right shoulder blade
• Timing: pain began after eating large fatty meal and lasts 5 hours
• Severity: 10/10
• Associated symptoms: nausea, 1 episode of non-bloody vomit
• Moving bowels regularly 2-3x per day, last BM this morning
• No history of abdominal surgery
• No significant past medical history
• Admits eating fast food regularly
• Denies trauma or injury, CP, SOB, jaundice, diarrhea, constipation, alcohol use
• Sexually active, uses contraception, not knowingly pregnant

Physical exam

• Vitals: 100 BPM regular, 135/88, RR 18, 100.1 F oral
• Uncomfortable appearing, obese female
• No rashes or jaundice
• Lungs clear, no adventitious sounds
• Tachycardic, regular rhythm, s1, s2, no murmurs
• Abd – No pulsations or ecchymoses, bowel sounds hypoactive, exquisitely tender RUQ, Murphy +

Differential:

• Cholecystitis
• Cholangitis
• Choledocholithiasis
• Appendicitis
• Hepatitis
• Pancreatitis
• Pregnancy

Tests

• CBC – leukocytosis, WBC >14, left shift
• LFT – WNL
• Lipase – WNL
• UA – WNL, no bacteria, blood, protein
• Pregnancy test – negative
• US RUQ – sonographic murphy sign, gallbladder enlarged with wall thickening >3 mm, sludging
• Abdominal CT – pericholecystic fluid, distended gallbladder with wall thickening

Treatment

• Admit for treatment
• NPO
• IV Hydration
• Pain control – ketorolac 30 mg IV q6 hours prn
• IV antibiotics – ceftriaxone 2 g IV daily, metronidazole 500 mg IV q8 hours

Pt Counseling

• Recommend definitive surgical treatment with laparoscopic cholecystectomy within 72 hours
• Counseled about lifestyle and diet – avoiding fatty foods, weight loss

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/acute-calculous-cholecystitis-clinical-features-and-diagnosis?search=acute%20cholecystitis&source=search_result&selectedTitle=1~124&usage_type=default&display_rank=1#H22

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/treatment-of-acute-calculous-cholecystitis?search=acute%20cholecystitis&source=search_result&selectedTitle=2~124&usage_type=default&display_rank=2#H11016944

https://radiopaedia.org/articles/acute-cholecystitis?lang=us

https://fpnotebook.com/Surgery/GI/ActChlcysts.htm