Emergency Department Encounter Note

Reason for Presentation

• This 52-year-old female presented via QAS at 09:15 on 14/05/2025 with acute right upper quadrant abdominal pain.

History of Presenting Illness

• The pain commenced suddenly at 06:00 this morning.
• She describes a constant, severe, dull ache in the right upper quadrant radiating to her interscapular region, rated 8/10 in severity.
• The pain is associated with nausea and two episodes of non-bilious vomiting.
• Symptoms began approximately two hours after consuming a high-fat meal.
• She reports three similar, milder self-limiting episodes over the past four months, which her GP, Dr SMITH, has been investigating.

Review of Systems

• She reports subjective fevers and chills overnight, and denies dysuria, haematuria, diarrhoea, or chest pain.

Management En Route with QAS

• QAS inserted an 18G IV cannula and administered fentanyl 50 mcg IV and ondansetron (Zofran) 4 mg IV at 08:45.
• Her pain score reduced from 8/10 to 4/10 and her nausea resolved prior to arrival.

Past Medical History

• Hypertension
• Type 2 diabetes mellitus
• Hyperlipidaemia
• Laparoscopic appendicectomy (2012)
• Depression
• General Practitioner: Dr SMITH

Medications

• metformin (Diabex) 1,000 mg PO BID
• perindopril (Coversyl) 5 mg PO daily
• atorvastatin (Lipitor) 20 mg PO daily
• sertraline (Zoloft) 50 mg PO daily

Allergies

• Penicillin (generalised maculopapular rash)

Social History

• She lives at home in Brisbane with her husband and is independent with all activities of daily living.

Drug, Tobacco, Alcohol History

• She consumes approximately 2 standard alcoholic drinks per week.
• She is a lifelong non-smoker.
• She denies any history of illicit or recreational drug use.

Family History

• Her mother had a cholecystectomy in her 40s for gallstone disease.

Immunisation History

• She is up to date with her routine immunisations, including recent influenza and COVID-19 boosters.

Examination

Vitals

• Weight: 88 kg
• Blood sugar level: 7.8 mmol/L
• Ketones: 0.2 mmol/L
• Temperature: 38.2 °C
• Blood pressure: 138/84 mmHg
• Heart rate: 98 beats/minute
• Oxygen saturation: 98% on room air

General: The patient appears uncomfortable and diaphoretic, clutching her right upper abdomen, with no clinical jaundice.

CVS: Dual heart sounds with no murmurs, peripheral pulses are strong and regular, and capillary refill time is under 2 seconds.

Resp: The chest is clear to auscultation bilaterally with equal air entry and no added sounds.

Abdo: The abdomen is soft with marked tenderness and guarding in the right upper quadrant, a positive Murphy's sign, and normal bowel sounds.

Neuro: She is alert and oriented to person, place, and time (GCS 15) with no focal neurological deficits.

MSK: She moves all four limbs freely with normal tone and power, and has no CVA tenderness.

Investigations

Bloods

• WCC: 14.8 x 10^9/L (Neutrophils: 11.9 x 10^9/L)
• Hb: 134 g/L, Plt: 265 x 10^9/L
• CRP: 72 mg/L
• Bilirubin: 16 µmol/L, ALP: 115 U/L, GGT: 58 U/L, ALT: 38 U/L, AST: 34 U/L
• Lipase: 32 U/L
• UEC: Na 138 mmol/L, K 4.1 mmol/L, Creatinine 68 µmol/L, eGFR > 90 mL/min/1.73m²
• Venous lactate: 1.3 mmol/L

Microbiology

• Urine dipstick: Negative for nitrites and leucocytes.
• Peripheral blood cultures: Collected and pending.

Radiology

• Abdominal Ultrasound: Distended, thick-walled gallbladder (5 mm) with multiple shadowing calculi, an impacted calculus in the gallbladder neck, pericholecystic fluid, a positive sonographic Murphy's sign, and a normal common bile duct measuring 4 mm.

• ECG: Sinus rhythm at 96 beats/minute with no acute ischaemic changes.

• Urine beta-hCG: Negative.

Assessment

• The primary diagnosis is acute calculous cholecystitis.
• Secondary issues include poorly controlled acute pain and mild dehydration secondary to vomiting.

Management in Emergency

• The patient received paracetamol (Panadol) 1,000 mg IV, oxycodone (Endone) 5 mg PO, ceftriaxone 2 g IV, metronidazole 500 mg IV, and 1,000 mL of 0.9% sodium chloride IV.
• Her pain decreased to 2/10 and her heart rate settled to 82 beats/minute following fluid resuscitation and analgesia.

Plan

• The patient will be admitted under the Acute Surgical Unit (Dr JONES).
• Keep the patient nil by mouth (NBM) in preparation for theatre.
• Commence maintenance IV fluids with 0.9% sodium chloride at 80 mL/hour.
• Chart regular paracetamol (Panadol) 1,000 mg IV QID, ceftriaxone 2 g IV daily, metronidazole 500 mg IV BID, and oxycodone (Endone) 5 mg PO Q4H PRN for breakthrough pain; withhold regular metformin (Diabex) while fasting.
• A formal referral has been accepted by Surgical Registrar Dr PATEL for inpatient laparoscopic cholecystectomy.
• Perform routine Q4H nursing observations, strict fluid balance charting, and QID blood sugar level monitoring.
• Transfer the patient to the surgical ward once a bed is available.