Quick answer
How should I present an acute appendicitis case on rounds?
Lead with the classic migration of pain from periumbilical to the right lower quadrant, since that pattern is highly specific. Give the peritoneal signs on exam, then the white count, CRP, and CT findings before naming acute appendicitis. End with NPO status, pre-operative antibiotics, and the surgical timeline, and flag any sign of perforation explicitly.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation once labs and CT results return.
The on-call general surgery team deciding on timing of appendectomy.
History, vital signs, a focused abdominal exam, white blood cell count, C-reactive protein, and CT abdomen and pelvis. Coagulation studies and allergy history are not itemized.
About 90 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Mr. Irwin is a 26-year-old man with no prior surgical history who presents with 18 hours of periumbilical pain that has migrated and intensified to his right lower quadrant, with fever and vomiting.
The pain started as a dull ache around his navel 12 hours ago and became sharp and constant in his right lower quadrant over the last 6 hours, with loss of appetite, nausea, one episode of vomiting after the pain started, and a low-grade fever. He is worried his appendix might be about to burst.
He has no prior surgery or health conditions and works as a software engineer.
His vitals show a temperature of 38 degrees Celsius, heart rate 98, and blood pressure 124 over 78. He has localized guarding, rebound tenderness, and maximal tenderness at McBurney's point, with positive Rovsing, psoas, and obturator signs. His white blood cell count is elevated at 15,800 with 86% neutrophils, CRP is elevated at 42, and CT shows an 11 millimeter dilated appendix with an appendicolith and fat stranding, without abscess or free air.
My diagnosis is acute uncomplicated appendicitis, based on the classic pain migration, peritoneal signs, and CT findings, with no evidence of perforation or abscess on imaging.
I would keep him NPO, start IV fluids and opioid analgesia, begin pre-operative broad-spectrum antibiotics covering enteric organisms, and obtain urgent surgical consultation for laparoscopic appendectomy within 12 to 24 hours.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Name the classic pain migration
“Mr. Irwin is a 26-year-old man with no prior surgical history who presents with 18 hours of periumbilical pain that has migrated and intensified to his right lower quadrant, with fever and vomiting.”
Why it belongs: Naming the migration from periumbilical to right-lower-quadrant pain in the first sentence is the single most classic and specific historical feature of appendicitis.
This is a 26-year-old with belly pain and fever.
Mr. Irwin has pain that migrated from around his navel to his right lower quadrant over 18 hours, with fever and vomiting.
Why: Naming the migration pattern is far more specific than a general description of abdominal pain.
History of present illness
Give the associated symptoms and his own concern
“The pain started as a dull ache around his navel 12 hours ago and became sharp and constant in his right lower quadrant over the last 6 hours, with loss of appetite, nausea, one episode of vomiting after the pain started, and a low-grade fever. He is worried his appendix might be about to burst.”
Why it belongs: Anorexia and vomiting occurring after, not before, the pain began is a specific sequence that supports appendicitis over a primary gastrointestinal illness, and his own fear of rupture is worth naming directly.
He has belly pain, nausea, and a fever.
His pain migrated from periumbilical to right-lower-quadrant over 18 hours, with anorexia, nausea, and vomiting that started after the pain began.
Why: The specific sequence and timing carry more diagnostic weight than a list of symptoms alone.
Relevant background
Confirm there is no complicating history
“He has no prior surgery or health conditions and works as a software engineer.”
Why it belongs: An unremarkable surgical history means there are no adhesions or prior abdominal procedures to complicate the differential or the planned surgical approach.
He's healthy otherwise.
He has no prior surgery or health conditions relevant to today's presentation.
Why: Stating there is no prior surgical history is directly relevant to planning a laparoscopic approach.
Objective data
State vitals, peritoneal signs, and the CT findings
“His vitals show a temperature of 38 degrees Celsius, heart rate 98, and blood pressure 124 over 78. He has localized guarding, rebound tenderness, and maximal tenderness at McBurney's point, with positive Rovsing, psoas, and obturator signs. His white blood cell count is elevated at 15,800 with 86% neutrophils, CRP is elevated at 42, and CT shows an 11 millimeter dilated appendix with an appendicolith and fat stranding, without abscess or free air.”
Why it belongs: The specific peritoneal signs localize the inflammation precisely, and the CT confirming an enlarged appendix without abscess or free air is what distinguishes uncomplicated from perforated appendicitis.
His exam and scan both showed appendicitis.
CT shows an 11 millimeter appendix with an appendicolith and fat stranding, without abscess or free air.
Why: Naming the exact size and the absence of abscess or free air is what actually rules out perforation on imaging.
Assessment
Commit to the diagnosis and its complication status
“My diagnosis is acute uncomplicated appendicitis, based on the classic pain migration, peritoneal signs, and CT findings, with no evidence of perforation or abscess on imaging.”
Why it belongs: Explicitly stating 'uncomplicated,' supported by the absence of abscess or free air, is what determines whether he goes for straightforward appendectomy or needs a different, staged approach.
This is appendicitis.
This is acute uncomplicated appendicitis, with no evidence of perforation or abscess on imaging.
Why: Naming the complication status directly affects the surgical plan.
Plan
State NPO status, antibiotics, and surgical timing
“I would keep him NPO, start IV fluids and opioid analgesia, begin pre-operative broad-spectrum antibiotics covering enteric organisms, and obtain urgent surgical consultation for laparoscopic appendectomy within 12 to 24 hours.”
Why it belongs: Naming the specific antibiotic coverage rationale and a concrete surgical timeframe shows a complete, actionable plan rather than a vague statement that surgery is needed.
I'll start antibiotics and get surgery to see him.
I would start pre-operative antibiotics covering enteric organisms and obtain surgical consultation for appendectomy within 12 to 24 hours.
Why: Naming the antibiotic rationale and a specific timeframe is more complete than a general statement.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Allergy and coagulation history
Say: “Allergy history and coagulation studies are not documented in this simulation and are needed before finalizing antibiotic choice and surgical clearance.”
Antibiotic selection and operative planning both depend on these safety checks.
Pregnancy status if relevant
Say: “This does not apply to this patient, but in a person of childbearing potential a pregnancy test would be part of the standard pre-operative workup.”
This is a general safety check worth naming as part of the complete pre-operative process.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Pain migrating from periumbilical to right lower quadrant over 18 hours | Lead | This is the single most classic and specific historical feature of appendicitis. |
| Anorexia, nausea, and vomiting starting after the pain began | Include | The specific sequence supports appendicitis over a primary gastrointestinal illness. |
| Works as a software engineer | Omit | Occupation does not change the surgical decision. |
| Positive Rovsing, psoas, and obturator signs with McBurney's point tenderness | Lead | These specific peritoneal signs localize the inflammation and support the diagnosis on exam alone. |
| CT showing an 11 millimeter appendix without abscess or free air | Lead | This is the decisive imaging finding confirming uncomplicated, not perforated, appendicitis. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
How do you know this isn't perforated?
CT shows an enlarged appendix with fat stranding but no abscess, free fluid collection, or free air, which are the imaging findings that would suggest perforation; his clinical exam also does not show a diffusely rigid abdomen.
Why give antibiotics before surgery if he's going to the operating room anyway?
Pre-operative antibiotics covering enteric gram-negative and anaerobic organisms reduce the risk of surgical-site infection and are given within the hour before incision as part of standard surgical care.
What would make you worry about perforation instead?
A diffusely rigid or peritonitic abdomen, high fever with marked tachycardia, or an abscess or free air on imaging would all raise concern for perforation and would change the surgical approach and urgency.
Self-check
A 30-second check before you present
- Name the migrating pain pattern in the opening sentence.
- State the specific sequence: pain first, then anorexia and vomiting.
- Name the specific peritoneal signs, not just 'tender abdomen.'
- Give white count, CRP, and CT findings with exact values.
- State explicitly whether imaging shows perforation or abscess.
- Name the antibiotic rationale, not just 'antibiotics given.'
- State a specific surgical timeframe.
- State what allergy or coagulation information is still needed.
Common presentation problems
Repair the habits that make a case hard to follow
Saying 'abdominal pain and fever' instead of describing the migration
Repair: State the specific periumbilical-to-right-lower-quadrant migration pattern.
Reporting 'CT showed appendicitis' without complication status
Repair: State explicitly whether abscess or free air is present.
Giving a vague surgical timeframe like 'soon'
Repair: State a specific window, such as 12 to 24 hours, for uncomplicated appendicitis.
Omitting allergy history before antibiotics
Repair: State that allergy history still needs to be confirmed.
Frequently asked questions
Oral case presentation questions
Do I need to name all three peritoneal signs?
Naming McBurney's point tenderness plus one or two additional positive signs, such as Rovsing's, is usually sufficient; be ready to describe all of them if asked.
Should I mention nonoperative management with antibiotics alone?
You can mention it exists as an option for select uncomplicated cases in some settings, but note that surgical consultation and shared decision-making should guide that choice rather than presenting it as the default here.
How long should this presentation be?
This worked example targets about 90 seconds. A patient with signs of perforation would need a more urgent, focused initial presentation.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case gs_001. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- Diagnosis and Treatment of Acute Appendicitis: 2020 Update of the WSES Jerusalem GuidelinesWorld Society of Emergency Surgery · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: