Quick answer
How should I present an acute cholecystitis case on rounds?
Lead with the postprandial right-upper-quadrant pain radiating to the shoulder blade after a fatty meal, since that pattern is classic. Give the elevated white count and the ultrasound findings, including the positive sonographic Murphy sign, before naming acute cholecystitis. End with the NPO, antibiotic, and surgical-consultation plan, and state that vital signs still need checking rather than assuming she is afebrile.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation once labs and right-upper-quadrant ultrasound results return.
A supervising physician arranging surgical consultation.
History, medications, social history, white blood cell count, bilirubin, lipase, and ultrasound. Vital signs and a formal abdominal exam are not yet supplied.
About 80 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.
Mrs. Garcia is a 52-year-old woman with obesity and type 2 diabetes who presents with six hours of steady, severe right-upper-quadrant pain that began an hour after a fatty meal.
The pain radiates to her right shoulder blade, with nausea, two episodes of bilious vomiting, and a subjective fever at home; she notices it is sharper with deep breathing, and she has had no jaundice or dark urine. She initially thought this was food poisoning but is now worried by the breathing-related pain.
Her history includes obesity with a BMI of 32, elevated cholesterol, and diet-controlled type 2 diabetes, and she takes atorvastatin; she drinks wine socially on weekends and works as an accountant.
Her white blood cell count is elevated at 15.2, total bilirubin is normal at 1.1, and lipase is normal at 34, arguing against pancreatitis. Ultrasound shows multiple gallstones, gallbladder wall thickening to 5 millimeters, trace pericholecystic fluid, a positive sonographic Murphy sign, and a normal common bile duct at 5 millimeters.
My diagnosis is acute cholecystitis secondary to gallstones, based on the sustained pain duration, elevated white count, and the positive sonographic Murphy sign with wall thickening, distinguishing it from uncomplicated biliary colic, which typically resolves within a few hours.
I would keep her NPO, start IV fluids, analgesia, and antiemetics, begin empiric IV antibiotics, and obtain surgical consultation for consideration of laparoscopic cholecystectomy.
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 pain pattern and its trigger
“Mrs. Garcia is a 52-year-old woman with obesity and type 2 diabetes who presents with six hours of steady, severe right-upper-quadrant pain that began an hour after a fatty meal.”
Why it belongs: Naming the postprandial timing and her risk factors for gallstones together in the opening sentence frames the classic presentation before any test result is given.
This is a 52-year-old with stomach pain after eating.
Mrs. Garcia has six hours of steady, severe right-upper-quadrant pain that began an hour after a fatty meal.
Why: Naming the specific location, duration, and trigger carries more diagnostic weight than a general description of stomach pain.
History of present illness
Give the radiation, associated symptoms, and her own concern
“The pain radiates to her right shoulder blade, with nausea, two episodes of bilious vomiting, and a subjective fever at home; she notices it is sharper with deep breathing, and she has had no jaundice or dark urine. She initially thought this was food poisoning but is now worried by the breathing-related pain.”
Why it belongs: Radiation to the shoulder blade and pain that worsens with inspiration are specific features supporting gallbladder inflammation rather than simple food poisoning.
The pain spreads to her back and gets worse sometimes.
The pain radiates to her right shoulder blade and is sharper with deep breathing.
Why: The specific radiation pattern and breathing-related worsening are more diagnostic than a vague description.
Relevant background
Name the gallstone risk factors
“Her history includes obesity with a BMI of 32, elevated cholesterol, and diet-controlled type 2 diabetes, and she takes atorvastatin; she drinks wine socially on weekends and works as an accountant.”
Why it belongs: Obesity and elevated cholesterol are recognized risk factors for gallstone disease and support the working diagnosis before imaging confirms it.
She has some risk factors for gallstones.
She has obesity with a BMI of 32 and elevated cholesterol, both recognized risk factors for gallstone disease.
Why: Naming the specific risk factors is more useful than a vague statement that risk factors exist.
Objective data
State the labs and the ultrasound findings
“Her white blood cell count is elevated at 15.2, total bilirubin is normal at 1.1, and lipase is normal at 34, arguing against pancreatitis. Ultrasound shows multiple gallstones, gallbladder wall thickening to 5 millimeters, trace pericholecystic fluid, a positive sonographic Murphy sign, and a normal common bile duct at 5 millimeters.”
Why it belongs: A normal lipase helps exclude pancreatitis as a competing diagnosis, and the specific ultrasound findings, especially the positive sonographic Murphy sign, are the objective evidence that confirms acute cholecystitis rather than uncomplicated biliary colic.
Her ultrasound showed gallstones and inflammation.
Ultrasound shows gallstones, wall thickening to 5 millimeters, and a positive sonographic Murphy sign.
Why: Naming the specific findings, especially the sonographic Murphy sign, is what actually distinguishes cholecystitis from simple gallstones.
Assessment
Commit to the diagnosis and separate it from biliary colic
“My diagnosis is acute cholecystitis secondary to gallstones, based on the sustained pain duration, elevated white count, and the positive sonographic Murphy sign with wall thickening, distinguishing it from uncomplicated biliary colic, which typically resolves within a few hours.”
Why it belongs: Explicitly distinguishing cholecystitis from biliary colic by duration and inflammatory markers shows the reasoning behind escalating from expectant management to admission and surgical consultation.
She has gallstones causing pain.
This is acute cholecystitis, distinguished from simple biliary colic by the sustained pain, elevated white count, and inflammatory ultrasound findings.
Why: Naming the distinguishing features explains why this is more than uncomplicated biliary colic.
Plan
State NPO status, antibiotics, and surgical consultation
“I would keep her NPO, start IV fluids, analgesia, and antiemetics, begin empiric IV antibiotics, and obtain surgical consultation for consideration of laparoscopic cholecystectomy.”
Why it belongs: This sequence addresses symptom control and infection risk while arranging the definitive surgical treatment, which is the standard approach once cholecystitis is confirmed.
I'll give antibiotics and get surgery to see her.
I would keep her NPO, start IV fluids and antibiotics, and obtain surgical consultation for cholecystectomy.
Why: Naming the full sequence, not just antibiotics, shows a complete management plan.
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.
Vital signs and abdominal exam
Say: “Vital signs and a formal abdominal exam, including a bedside Murphy sign, are not documented in this simulation beyond the subjective fever at home, and I would assess them directly.”
Do not describe her as afebrile or hemodynamically stable without measuring it.
MRCP or ERCP if bile duct obstruction develops
Say: “Her ultrasound already shows a normal-caliber common bile duct and her bilirubin is normal, so choledocholithiasis is not currently suggested; further imaging such as MRCP is not part of this simulation and would only be considered if bilirubin or liver enzymes were to rise.”
A normal duct on ultrasound and normal bilirubin argue against choledocholithiasis now, but a new rise in either would warrant direct duct imaging before assuming it stays excluded.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Six hours of steady RUQ pain radiating to the shoulder blade after a fatty meal | Lead | This pattern and duration are the classic presenting features of acute cholecystitis. |
| Pain sharper with deep breathing | Include | This supports gallbladder inflammation irritating the adjacent diaphragm. |
| Works as an accountant, drinks wine socially | Omit | This detail does not change the immediate diagnostic or treatment decision. |
| Positive sonographic Murphy sign with wall thickening to 5 millimeters | Lead | This is the specific ultrasound finding that confirms cholecystitis rather than simple gallstones. |
| Normal lipase and bilirubin | Include | These relevant negatives help exclude pancreatitis and significant bile duct obstruction. |
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 just biliary colic?
Biliary colic typically resolves within a few hours; sustained pain beyond that, along with an elevated white count and inflammatory ultrasound findings like wall thickening and a positive sonographic Murphy sign, distinguishes acute cholecystitis, which needs antibiotics and surgical evaluation rather than expectant management alone.
Why check lipase in a suspected gallbladder case?
Gallstones can also cause gallstone pancreatitis, so checking lipase helps distinguish isolated cholecystitis from a case with pancreatic involvement, which would change the urgency and management.
When should cholecystectomy happen?
Early laparoscopic cholecystectomy, often within the same admission, is generally preferred once she is stabilized; the exact timing depends on her surgical fitness and local surgical availability, which are not detailed in this simulation.
Self-check
A 30-second check before you present
- Name the postprandial timing and shoulder-blade radiation in the opening sentence.
- State the specific negatives, such as no jaundice, if relevant.
- Give white count, bilirubin, and lipase with exact values.
- Name the specific ultrasound findings, especially the sonographic Murphy sign.
- Distinguish cholecystitis from biliary colic explicitly by duration and inflammation.
- State that vital signs and a bedside exam are still needed.
- Give the NPO, antibiotic, and surgical-consultation plan together.
- Note what further imaging would be considered if bilirubin rises.
Common presentation problems
Repair the habits that make a case hard to follow
Calling this biliary colic despite six hours of sustained pain
Repair: State the duration and inflammatory findings that distinguish cholecystitis.
Assuming she is afebrile because a fever wasn't mentioned
Repair: State that vital signs are not yet measured and are being checked directly.
Omitting the sonographic Murphy sign
Repair: State it explicitly, since it is a key finding that supports the diagnosis.
Treating antibiotics as the only necessary step
Repair: State that surgical consultation for cholecystectomy is also part of the plan.
Frequently asked questions
Oral case presentation questions
Do I need to name the specific antibiotic?
State that empiric antibiotics are started per local protocol; naming a specific agent is reasonable if your program expects it, but the choice depends on local resistance patterns and allergies.
Should I mention the Tokyo Guidelines severity grade?
Yes, if your program uses it, since it helps communicate severity and urgency concisely; otherwise, describing the specific findings that support the diagnosis is sufficient.
How long should this presentation be?
This worked example targets about 80 seconds. A patient with signs of sepsis or gallbladder perforation would need a more urgent, shorter 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 gi_005. 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.
- Tokyo Guidelines 2018: Diagnostic Criteria and Severity Grading of Acute CholecystitisJournal of Hepato-Biliary-Pancreatic Sciences · 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: