[Age]-yo [M/F] with PMH of..., presenting with

*** days
constant/intermitent
progressively worsening/improving
CC: RUQ abdominal pain
gradual/Acute onset,
PP: pain worse with eating, +fever and N/V
PN: denies jaundice, hematemesis, melena, hematochezia, chest pain, SOB
pertinent SHx: tobacco, EtOH, drug use
initial DATA: CBC (WBC) CMP(Mild ↑AST/ALT, nl bili), elv CRP Alk Phos mildly elevated, lipase normal, positive Murphy sign
pending DATA: RUQ ultrasound ((thickening of wall, distention >40, Pericholecystic fluid) , blood cultures if febrile,
MEDS:
COURSE:

Plan

consult surgery for Early cholecystectomy i pt stable (within 24–72 hrs)
Too sick = drain now, surgery later, too high risk or not medically optimized (eg, septic shock/hemodynamic instability, severe respiratory failure, decompensated CHF, active MI/severe arrhythmia, unreversed anticoagulation, severe cirrhosis, marked frailty/prohibitive surgical risk, or extensive local inflammation), and stabilize first. -> consult surgery for Percutaneous Cholecystostomy if in icu for a while, usually 4–7 days total antibiotics
IV antibiotics (ceftriaxone + metronidazole) can stop 24 hr after cholecystectomy
IVF and replete Lytes as needed
NPO for now
Pain control: APAP -> Ketorolac(toradol) (15-30mg every 6 hours.) unless AKI/CKD (opioid inc spasm of sphinter of oddi) if CI to NSAIDS (AKI/CKD/GIB) will use diludid PRN
Bcx and Lactate if shock/hemodynamicly unstable
HIDA if Normal undeterminent but suspicion high

Note:

DX: RUQ ultrasound in a patient with RUQ pain/fever/Murphy sign.
can remove Abs 24 hr after cholecysecectomy,
if sick cant do surgery 7-10 day if longer abx then 6-8 week then cholecysecectomy
emergent surgery in emphysematous ,necrosis perforation.

Post-fatty meal episodic RUQ pain + normal labs = Cholelithiasis
Constant RUQ pain + fever + ↑WBC + Murphy sign = Acute Cholecystitis
Jaundice ± RUQ pain + ↑bilirubin + ↑Alk Phos (no fever) = Choledocholithiasis
Fever + jaundice + RUQ pain + ↑WBC + cholestatic labs = Cholangitis

RDYS