Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with recurrent episodes of biliary-type pain localized to the right upper quadrant (RUQ) or epigastrium. Pain is described as [steady/cramping], lasting [duration], and often exacerbated by fatty food ingestion. Associated symptoms include [nausea/vomiting/bloating]. Patient denies fever, jaundice, or dark urine. Previous imaging (US) negative for cholelithiasis. HIDA scan demonstrates gallbladder ejection fraction (GBEF) of [X]%.
Clinical Examination Findings
Abdomen is soft, non-distended. Significant tenderness to palpation in the RUQ. Murphy’s sign is [positive/negative]. No palpable masses, organomegaly, or rebound tenderness. Bowel sounds are present and normoactive. No scleral icterus or skin jaundice noted.
Treatment Protocol
Plan: Discussed surgical management via laparoscopic cholecystectomy. Risks, benefits, and alternatives explained, including potential for persistent symptoms post-operatively. Patient advised on low-fat diet pending surgery. Scheduled for elective laparoscopic cholecystectomy.