The Patient Presentation introduces the individual, their symptoms, and the circumstances that brought them to medical attention. It establishes the starting point for the entire surgical journey.

Each presentation should include:

• Patient profile: Age, sex, relevant occupation, activity level, and living situation

• Chief complaint: The patient’s primary concern in their own words

• History of present illness: Symptom onset, location, duration, severity, progression, triggers, and relieving factors

• Associated symptoms: Additional findings that help define the condition

• Medical and surgical history: Existing illnesses, prior operations, anesthesia history, and previous treatments

• Medications and allergies: Prescription drugs, supplements, anticoagulants, and known reactions

• Family and social history: Relevant hereditary risks, tobacco or alcohol use, nutrition, and available support

• Initial assessment: Vital signs, physical examination, and notable clinical findings

• Patient concerns: Questions, fears, expectations, and personal treatment goals

• Urgency level: Elective, time-sensitive, urgent, or emergent

Example: Acute Cholecystitis

A 35-year-old woman presents with persistent right upper-quadrant abdominal pain that began several hours after eating a fatty meal. The pain radiates toward her right shoulder and back and is accompanied by nausea, vomiting, reduced appetite, and a low-grade fever.

Examination reveals right upper-quadrant tenderness and a positive Murphy sign. Her symptoms and initial findings raise concern for acute gallbladder inflammation, prompting laboratory testing and abdominal ultrasound.

Patient’s central questions:

• What is causing the pain?

• Is this an emergency?

• Will I need surgery?

• What treatment options are available?

• How long will recovery take?

This scenario is designed for education and shared decision support and does not replace evaluation by a qualified healthcare professional.

Patient

A 35-year-old woman presents with persistent right upper-quadrant abdominal pain, nausea, vomiting, and intolerance of fatty foods. The pain may radiate toward her right shoulder or back.

Immediate Assessment

The clinical team first determines whether the patient is stable:

• Airway, breathing, and circulation assessed

• Vital signs obtained

• Pain severity documented

• Hydration status evaluated

• IV access established

• Pregnancy status confirmed

• Signs of sepsis, jaundice, or peritonitis assessed

Focused History

Important questions include:

• When did the pain begin?

• Is it constant or intermittent?

• Did it start after eating?

• Does it radiate to the shoulder or back?

• Are fever, chills, nausea, or vomiting present?

• Has she experienced similar episodes?

• Is there dark urine, pale stool, or yellowing of the skin?

• Does she take anticoagulants or have medication allergies?

• Has she had prior abdominal surgery?

Physical Examination

Expected findings may include:

• Right upper-quadrant tenderness

• Guarding over the gallbladder region

• Positive Murphy sign

• Low-grade fever

• Mild tachycardia

• Possible dehydration

The examination should also look for generalized rigidity, rebound tenderness, hypotension, confusion, or jaundice—findings that may indicate a complication or another diagnosis.

Initial Diagnostic Workup

• Complete blood count

• Comprehensive metabolic panel

• AST, ALT, alkaline phosphatase, and bilirubin

• Lipase

• Urinalysis

• Pregnancy test

• Right upper-quadrant ultrasound

Additional imaging—such as HIDA scan, MRCP, or CT—may be considered when the diagnosis remains uncertain or a complication is suspected.

Case Findings

Ultrasound demonstrates:

• Multiple gallstones

• One stone impacted near the gallbladder neck

• Gallbladder wall thickness of 5 mm

• Mild gallbladder distention

• Small amount of pericholecystic fluid

• Positive sonographic Murphy sign

• Common bile duct measuring 4 mm without dilation

• No definite common bile duct stone

Initial Clinical Impression

The presentation and ultrasound findings are strongly consistent with acute calculous cholecystitis caused by an impacted gallstone obstructing the cystic duct or gallbladder neck.

Immediate Management

• Nothing by mouth

• IV fluids

• Pain control

• Antiemetic medication

• Antibiotics when clinically indicated

• Surgical consultation

• Assessment for early laparoscopic or robotic cholecystectomy

Safety Escalation

Urgent intervention is required if the patient develops:

• Hemodynamic instability

• Sepsis

• Progressive jaundice

• Generalized peritonitis

• Suspected gallbladder gangrene or perforation

• Ascending cholangitis

• Gallstone pancreatitis

Clinical Scenarios in Surgery™
From first assessment to informed surgical decision-making.

Scenario: 35-year-old female with right upper-quadrant pain and suspected acute cholecystitis.

1. Assess clinical stability

   • Airway, breathing, circulation

   • Vital signs and oxygen saturation

   • Pain severity and mental status

   • Look for hypotension, tachycardia, fever, hypoxia, or sepsis

   2. Keep the patient NPO

   Stop oral food and fluids while diagnostic evaluation and possible surgery are underway.

   3. Establish IV access

   • Begin isotonic IV fluids as clinically indicated

   • Correct dehydration and electrolyte abnormalities

   • Obtain blood cultures before antibiotics if sepsis is suspected and this will not delay treatment

     4. Control symptoms

   • Provide appropriate analgesia

   • Administer antiemetic medication

   • Reassess pain, abdominal findings, and response to treatment

   5. Order the initial workup

   • CBC

   • Comprehensive metabolic panel

   • AST, ALT, alkaline phosphatase, and bilirubin

   • Lipase

   • Pregnancy test when applicable

   • Coagulation studies and lactate for selected or unstable patients

   • Right-upper-quadrant ultrasound as first-line imaging

   6. Begin antimicrobial therapy when acute cholecystitis is suspected

   Select antibiotics according to illness severity, allergies, local resistance patterns, renal function, and institutional protocol.

   7. Request early surgical evaluation

   Consult general surgery promptly. For a stable patient who is an appropriate operative candidate, plan early laparoscopic cholecystectomy during the same hospitalization.

   8. Identify urgent escalation findings

   Escalate immediately for:

   • Hemodynamic instability or organ dysfunction

   • Sepsis or septic shock

   • Generalized peritonitis

   • Gallbladder perforation, gangrene, or emphysematous cholecystitis

   • Jaundice with suspected biliary obstruction

   • Fever, jaundice, and systemic illness suggesting acute cholangitis

   9. Determine whether additional biliary intervention is needed

   MRCP, endoscopic ultrasound, intraoperative cholangiography, or ERCP may be considered when choledocholithiasis or cholangitis is suspected. ERCP is not routine for uncomplicated cholecystitis.

Immediate objective: Stabilize the patient, control pain and infection, confirm the diagnosis, detect complications, and move efficiently toward definitive treatment.

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