Biliary Colic
Age: years old
Gender:
HISTORY:
Presents with a - history of pain
Onset was , started
Radiation to
Rated at / 10
Described as
Pattern
Episodes last for , recur times per
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, episodes , ,
, up to °, over
, over ,
, , , ,
Contributing factors:
no history of: ,
no use of:
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: gallstones, cholecystitis, choledocholithiasis, pancreatitis, gastritis, peptic ulcer disease, gastroenteritis, appendicitis, functional abdominal pain, abdominal wall pain, inflammatory bowel disease, irritable bowel syndrome, pyelonephritis, renal colic, kidney stones, myocardial infarction, pneumonia with referred pain, abdominal aortic aneurysm, mesenteric ischemia, herpes zoster, sickle cell crisis
PLAN:
Investigations:
- Blood work: , , , , ,
- Abdominal ultrasound
- CT scan of abdomen
- HIDA scan
- MRCP
- ERCP
Treatments:
-
-
-
- , if cholecystitis suspected
- Low fat diet
- Increase fluid intake
- Avoidance of rapid weight loss
Further care:
- Referral to general surgeon
- Referral to gastroenterologist
- Follow-up in
- Return if pain worsens, fever develops, jaundice appears, or if new symptoms develop such as vomiting or changes in stool color
- Referral to ER if severe abdominal pain, severe vomiting, or fever
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: