CCS Case: Acute Cholecystitis

Case: Acute Cholecystitis

Clinical Setup

• Presentation: 52-year-old obese female with 10 hours of RUQ pain radiating to right shoulder, fever 38.4°C, vomiting, positive Murphy’s sign, RUQ tenderness with guarding.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • IV access, Normal saline 0.9% IV @ 150 mL/hr.
   • NPO stat; IV ondansetron for nausea.
2. Focused Exam (Minute 1–2):
   • RUQ exam (Murphy’s sign, peritoneal signs), vital trend, jaundice check.
3. Diagnostics (Minute 2–5):
   • CBC with differential (leukocytosis), CMP (bilirubin, ALP, transaminases), lipase, PT/INR, PTT, Type and Screen.
   • RUQ ultrasound stat (gallstones, wall thickening, pericholecystic fluid, sonographic Murphy’s).
   • HIDA scan only if ultrasound equivocal.
4. Therapeutics (Minute 5–15):
   • IV pain control (morphine or fentanyl).
   • IV antibiotics: e.g., Ceftriaxone + Metronidazole (cover gram-negative + anaerobes).
   • General surgery consult stat for laparoscopic cholecystectomy within 24–72 hours (early surgery preferred).
   • If unstable/septic with prohibitive surgical risk: percutaneous cholecystostomy via IR.
5. Disposition (Minute 15–20):
   • Admit to surgical service; NPO until OR.
   • Monitor for gangrenous/perforated gallbladder (worsening pain, hypotension, rising WBC).
6. Final 2 Minutes:
   • Counsel on post-op diet advancement, wound care, activity restrictions.
   • Schedule post-op surgery follow-up; discuss weight management and lipid control.