Patient
62-year-old male, surgical consultation
Consultation Indication
Referred by Dr. Sarah Chen (Gastroenterology) for elective laparoscopic cholecystectomy evaluation. Patient has symptomatic cholelithiasis with 3 documented episodes of biliary colic in the past 4 months, most recent requiring ED visit 2 weeks ago. Ultrasound confirms multiple gallstones, largest 14 mm, with thickened gallbladder wall (5 mm). No evidence of choledocholithiasis on MRCP.
History of Present Illness
First episode of RUQ pain 4 months ago — postprandial, lasting 4 hours, resolved spontaneously. Second episode 6 weeks ago, similar character. Third episode 2 weeks ago: severe RUQ pain radiating to right scapula, associated with nausea and vomiting. Presented to ED, given analgesics, discharged with surgery referral. No fever, jaundice, or cholangitis symptoms at any point.
Past Surgical History
Appendectomy (age 18, open). Left knee arthroscopy (age 45). No prior abdominal surgery other than appendectomy.
Comorbidities
Type 2 Diabetes Mellitus (dx 8y, on metformin 1000mg BID, HbA1c 7.4% last month)
Obesity Class I (BMI 34.2 kg/m2)
Obstructive Sleep Apnea (diagnosed 3y ago, CPAP compliant, AHI 12/h on treatment)
Coronary artery disease (PCI with stent 2018; aspirin 81 mg, metoprolol succinate 25 mg daily)
Hyperlipidemia (rosuvastatin 10mg, LDL 94)
HTN (lisinopril 10mg, well-controlled)
Cardiac Risk Assessment
RCRI score: 2 points (ischemic heart disease — remote stent 2018, asymptomatic, stress test 2023 negative; intraperitoneal surgery). Diabetes not counted (not on insulin); creatinine 1.0.
Functional status: METs >4 (walks 1 mile daily, climbs 2 flights without symptoms)
Echocardiogram (2024): EF 55%, mild concentric LVH, grade I diastolic dysfunction, no valvular disease, normal RV size and function
ACC/AHA perioperative risk: elevated (RCRI 2), but functional capacity >4 METs — no further cardiac testing indicated
Cardiology input: continue metoprolol and aspirin through the perioperative period; no additional cardiac testing indicated.
Physical Examination
Abdomen: soft, non-distended, +BS x4 quadrants. Tenderness to deep palpation in RUQ, positive Murphy's sign (mild). No rebound or guarding. No hepatosplenomegaly. No masses. Well-healed appendectomy scar RLQ.
Vitals: BP 134/82, HR 72, RR 16, SpO2 96% RA, 98.8 F
Labs
CBC: WBC 7.2, Hgb 14.8, Plt 245 — normal
CMP: Na 139, K 4.3, Cr 1.0, TBili 0.8, AST 22, ALT 28, Alk Phos 78 — normal
Coag: INR 1.0, PTT 28 — normal
HbA1c: 7.4%
Surgical Plan
Procedure: Laparoscopic Cholecystectomy, elective
Approach: Standard 4-port technique, French position
Antibiotic prophylaxis: Cefazolin 2g IV within 60 min of incision
DVT prophylaxis: SCDs + unfractionated heparin 5000U SC pre-op
Glucose management: Check fingerstick q4h perioperatively, hold morning metformin, restart POD 1
CPAP: Bring from home, use immediately post-extubation in PACU
Estimated blood loss: <50 mL
Expected discharge: Same-day discharge or POD 1
Consent Discussion
Risks reviewed with patient and spouse: bleeding, infection, bile duct injury (~0.3-0.5%), conversion to open (~5%), bowel injury, retained stones, post-cholecystectomy syndrome. Patient verbalizes understanding. Questions answered. Consent signed and witnessed.
Assessment & Plan
Symptomatic cholelithiasis, surgical candidate for elective laparoscopic cholecystectomy. ASA III (optimized comorbidities). Cardiac clearance obtained. Proceeding to OR scheduling.
- Schedule elective LC — OR coordination calling with dates
- Pre-op optimization: continue aspirin, metoprolol, and statin; hold lisinopril the morning of surgery; bring CPAP day-of-surgery
- NPO after midnight before surgery
- Hold metformin day of surgery, resume POD 1
- Post-op: diet advance, ambulate evening of surgery, discharge when tolerating PO/pain controlled