History

HPI overview

Key features

OPQRST

Onset

Provocation and palliation

Quality

Region and radiation

Severity

Timing

Associated symptoms

GI and hepatobiliary

Infection and systemic

Cardiorespiratory

GU and gyn

Context and exposures

Recent events

Food and toxin exposures

Special populations

Pregnancy

Immunocompromised

Anticoagulated

Alarm Features

Immediate escalation triggers

Resuscitation triggers

Sepsis and cholangitis red flags

High risk infection features

Vascular catastrophe red flags

Aortic and mesenteric concern

Peritonitis and perforation red flags

Surgical abdomen features

Cardiac and pulmonary red flags

High risk cardiopulmonary features

Medications

Medication reconciliation

Current medications

High risk medication exposures

Hepatobiliary relevant meds

Bleeding risk meds

Contraindications and interactions

Common ED therapies

Diet

Recent intake and triggers

Patterns

Hydration and alcohol

Exposures

Review of Systems

GI and hepatobiliary

Key symptoms

Constitutional and infectious

Systemic symptoms

Cardiorespiratory

Chest and lung symptoms

GU and gyn

GU and pelvic symptoms

Skin and neuro

Other symptoms

Collateral History and Family History

Collateral source

Reliability

Family history

Relevant conditions

Risk Factors

Hepatobiliary and pancreatic

Gallstone risk

Pancreatitis risk

Infection and obstruction

Biliary infection risk

Vascular and thrombotic

Thromboembolism risk

Aortic risk

Cardiac risk

Coronary risk factors

Differential Diagnosis

Life threatening

Cannot miss

Common

Frequent causes

Less common

Important alternatives

Past Medical History

Relevant conditions

Hepatobiliary history

Cardiac and vascular history

Surgical and device history

Physical Exam

General and vitals interpretation

Appearance and perfusion

Vital sign patterns

Abdominal exam

RUQ focused findings

Hepatobiliary signs

Cardiorespiratory exam

Heart and lungs

Skin and neuro

Targeted findings

Extremities and vascular

Perfusion and thrombosis

Lab Studies

Core labs

Baseline evaluation

Hepatobiliary panel

Pancreatic and perfusion

Coagulation and pregnancy

Infection and sepsis workup

When febrile or unstable

Interpretation pearls

Pattern recognition

Pitfalls

Limitations

Imaging

Scoring Systems

Severity and criteria tools

MRI

MRCP

CT

CT abdomen pelvis with IV contrast

CT angiography chest abdomen pelvis

Ultrasound

RUQ ultrasound

POCUS gallbladder and biliary

Ultrasound aorta

Special Tests

Bedside maneuvers

Focused tests

Targeted serologies and toxicology

When indicated

Procedures

Diagnostic and therapeutic pathways

ECG

Indications and timing

When to obtain

High risk patterns

Ischemia and conduction

Assessment

Working problem list

RUQ pain syndrome

Alternate life threats

Severity stratification

Infection severity

Obstruction concern

Plan

First 5 minutes

Stabilization

Analgesia and antiemetics

Symptom control

Antibiotics

Suspected cholecystitis or cholangitis

Diagnostic sequencing

Testing priorities

Consultation

Time critical consults

Reassessment loop

Repeat checks

Disposition

ICU and high acuity criteria

Critical care needs

Admission criteria

Inpatient indications

Observation criteria

Short stay pathways

Discharge criteria

Safe discharge features

Discharge Instructions

Copy discharge instructions

Summary

Medications

Diet and activity

Follow up

References

Guidelines and key sources

Tokyo Guidelines 2018 for acute cholangitis and acute cholecystitis

World Society of Emergency Surgery guidelines for acute calculous cholecystitis 2020

American College of Gastroenterology guideline for acute pancreatitis 2013

Surviving Sepsis Campaign guidelines 2021

American Heart Association and ACC guidance for ACS evaluation