History taking in general surgery with viva questions

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History Taking in General Surgery

Sourced from Bailey & Love's Short Practice of Surgery (28th ed.) and Pye's Surgical Handicraft (22nd ed.)

Why History Matters

"With care and experience, a careful history will provide over 70% of the information required to reach the correct diagnosis" - and if history + examination are combined, the figure rises above 85%.

Pye's Surgical Handicraft, p. 113

The experienced surgeon begins observing before a word is spoken - gait, facial expression, position in bed, and tone of speech all offer diagnostic clues.

Structure of a Surgical History

1. Introduction and Rapport

Introduce yourself and establish privacy
Gain consent to begin the consultation
Allow the patient to speak without interruption first
Ease anxiety - a tense patient gives an unreliable abdominal examination
Use a chaperone when appropriate (especially in paediatric patients)

2. Presenting Complaint (PC)

Start with an open question: "What brought you to see us today?"

Then use directed questions to refine:

Feature to Elicit	What to Ask
Duration	How long has this been present?
Onset	Sudden vs gradual?
Character/Nature	Aching, sharp, colicky, burning, constant?
Site	Where exactly? Point to it
Radiation	Does it spread anywhere?
Severity	Score out of 10; effect on daily activities
Aggravating factors	Food, movement, breathing, defecation?
Relieving factors	Rest, posture, antacids, analgesics?
Associated symptoms	Nausea, vomiting, fever, weight loss, jaundice

Pain - The SOCRATES Mnemonic

Site
Onset
Character
Radiation
Associations
Time course / duration
Exacerbating / relieving factors
Severity

"In the acute situation, pain is the most common presenting feature." - Bailey & Love, p. 1073

Classic Pain Patterns to Know

Condition	Site	Radiation	Key Feature
Biliary colic	RUQ	Tip of right scapula	Triggered by fatty meal
Acute appendicitis	Periumbilical → RIF	-	Migration is pathognomonic
Acute pancreatitis	Epigastrium	Back (band-like)	Abrupt onset, severe
Peptic ulcer perforation	Epigastrium	Back	Board-like rigidity
Ureteric colic	Flank	Groin/scrotum	Haematuria
Intestinal obstruction	Periumbilical (colicky)	-	Distension, absolute constipation
Leaking AAA	Epigastric/back	-	Pulsatile mass, shock

3. Past Medical History (PMH)

Elicit:

Previous similar episodes - recurrent RIF pain may suggest Crohn's disease, ileocaecal TB, or amoebic typhlitis
Previous abdominal surgery - adhesions are the commonest cause of small bowel obstruction
Previous laparotomy - particularly relevant in bowel obstruction
Comorbidities: diabetes mellitus, TB, cardiac disease, rheumatic fever, haematological conditions (sickle cell causing abdominal pain, bleeding disorders)
Myocardial infarction: surgery within 3-6 months of an MI carries a 75% risk of re-infarction, with 25% mortality - an important surgical contraindication

4. Drug History and Allergies

Critical for surgical patients:

Drug	Surgical Implication
Beta-blockers	Masks tachycardia of haemorrhage
Corticosteroids (long-term)	Requires IV steroid cover perioperatively (adrenal crisis risk)
Anticoagulants (warfarin, NOACs)	Must be reversed/bridged before surgery
NSAIDs / Aspirin	Risk of GI haemorrhage
Oral contraceptive pill	Increased risk of DVT post-surgery
Insulin / oral hypoglycaemics	Sliding scale insulin required perioperatively

Always ask about allergies - to drugs, anaesthetic agents, latex, iodine.

"It is not uncommon for a patient to deny symptoms of cardiorespiratory disease, only for the doctor to find the patient is on drugs which have clearly treated such disease effectively!" - Pye's, p. 113

5. Social History (SH)

Smoking - pulmonary complications risk, wound healing, malignancy
Alcohol - hepatic function, coagulopathy, withdrawal risk, delirium tremens
Illicit drug use
Occupation - industrial hazards (asbestos → mesothelioma; aniline dyes → bladder cancer); whether a hernia arose during heavy lifting
Domestic circumstances - affects discharge planning, need for home support or convalescent care

6. Family History (FH)

Ask specifically about:

Colorectal cancer (FAP, Lynch syndrome)
Inflammatory bowel disease (Crohn's, UC)
Gallstones and duodenal ulceration
Endocrine disorders - hyperparathyroidism (renal calculi, peptic ulcers)
Genetic conditions - adverse reactions to anaesthetics (malignant hyperthermia - RYR1/CACNA1A mutations)
Diabetes mellitus / TB (within the family may mimic or cause surgical presentations)

7. Systematic Enquiry (Review of Systems)

This is not optional in surgery. It achieves three purposes:

Identifies additional features overlooked in the presenting complaint
May reveal a more significant diagnosis - e.g., symptoms of lung cancer in a patient presenting with a hernia
Establishes fitness for anaesthesia - a core surgical obligation

Systems to review:

Cardiovascular: chest pain, dyspnoea, palpitations, ankle swelling, exercise tolerance
Respiratory: cough, dyspnoea, haemoptysis, wheeze
GI: dysphagia, heartburn, nausea, vomiting, haematemesis, melaena, PR bleeding, bowel habit changes
Urological: dysuria, frequency, haematuria, stream, nocturia
Gynaecological (female patients): LMP, pregnancy status, menorrhagia, discharge
Neurological: headache, visual changes, weakness, parasthesia
Constitutional: fever, weight loss, night sweats, fatigue, anorexia

"The most important adage of all is 'above all else, to do no harm'." - Pye's Surgical Handicraft

Key Symptom Analysis in Surgery

Altered Bowel Habit

Pattern	Likely Diagnosis
Longstanding diarrhoea, left pain easing post-defecation	IBS
Recent onset diarrhoea + blood/mucus	Colonic carcinoma or IBD
Progressive change + acute obstruction	Stenotic left colon cancer
Absolute constipation + distension	Mechanical bowel obstruction
Marked distension + RIF tenderness	Closed-loop obstruction, caecal rupture risk

Weight Loss and Anorexia

Insidious weight loss with anorexia should always raise concern for malignancy:

Right colon cancer → anaemia (occult blood loss)
Gastric cancer → anorexia and early satiety
Liver metastases → weight loss
Ovarian cancer → abdominal distension
Biliary malignancy → painless jaundice

Jaundice

Establish: onset (sudden vs gradual), colour of urine/stools, pruritus, fever (Charcot's triad), pain, weight loss, alcohol use.

Haematemesis / Melaena / PR Bleeding

Haematemesis: bright red (arterial) vs coffee-ground (slower/gastric)
Melaena implies a source proximal to the splenic flexure
PR bright red blood: lower GI source; mix with stool = right colon; fresh on toilet paper = haemorrhoids

Special Considerations

Acute vs Elective Presentation

In acute settings: focus rapidly on pain characterisation, vital signs, time of last meal, and contraindications to emergency surgery.

In elective settings: full systematic approach with comprehensive pre-anaesthetic assessment.

Paediatric and Elderly Patients

Children: obtain history from parents but attempt to include the child
Elderly: note cognitive baseline, polypharmacy, fall history, functional status

Female Patients

Always ask:

Last menstrual period (LMP) - exclude ectopic pregnancy in women of reproductive age with lower abdominal pain
Pregnancy status - mandatory before any imaging or anaesthesia
Gynaecological history - ovarian pathology, PID, endometriosis

Principles of History Taking - Summary Box

(from Bailey & Love, p. 1074)

Identify the reason for consultation - the presenting complaint
Determine the onset, duration and evolution of symptoms
Deduce the most likely organ or system affected
Refine history with relevant direct questions
Establish relevant past, social, family, drug and allergy history
Complete with a thorough review of systems
Devise a differential diagnosis list

Viva Questions - History Taking in General Surgery

Basic / Foundation Level

Q1. What percentage of diagnoses can be made from history alone? A: Over 70% from history alone; over 85% when combined with clinical examination (Pye's Surgical Handicraft).

Q2. What is the SOCRATES mnemonic for pain history? A: Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/relieving factors, Severity.

Q3. Why do you ask about previous abdominal surgery in a patient with intestinal obstruction? A: Adhesions from previous laparotomy are the most common cause of small bowel obstruction. The history directly predicts the likely aetiology.

Q4. A patient is on long-term steroids. What is the surgical concern? A: Suppression of the hypothalamic-pituitary-adrenal axis means the patient cannot mount an appropriate cortisol response to surgical stress. IV steroid supplementation (hydrocortisone cover) is required to prevent an adrenal (Addisonian) crisis perioperatively.

Q5. What does it mean if a bleeding patient is on a beta-blocker? A: The reflex tachycardia of haemorrhage is blunted. The patient may have significant blood loss without a proportionate rise in heart rate, giving a falsely reassuring picture.

Q6. Why must you ask about the last menstrual period in a young woman with RIF pain? A: To exclude ectopic pregnancy, which classically presents with right or left iliac fossa pain and can be life-threatening if ruptured. It must be considered before any investigation or surgical intervention.

Intermediate Level

Q7. Where does pain from the appendix initially localise and why does it shift? A: Initially periumbilical (visceral pain from midgut - T10 dermatome, autonomic innervation). As inflammation spreads to the parietal peritoneum of the right iliac fossa (somatic innervation by iliohypogastric / intercostal nerves), pain localises to McBurney's point. This migration is pathognomonic of appendicitis.

Q8. Describe the pain of biliary colic and explain its pathophysiology. A: Colicky right upper quadrant pain radiating to the tip of the right scapula, precipitated by fatty meals. A fatty meal releases cholecystokinin (CCK), which causes gallbladder contraction against an obstructed cystic duct (by a stone). The pain is referred to the right scapular tip via the right phrenic nerve (C3-C5 dermatome shared with right shoulder).

Q9. What are Charcot's triad and what does it suggest? A: Right upper quadrant pain + fever + jaundice = ascending cholangitis (infection of the biliary tree, usually from choledocholithiasis). Reynolds' pentad adds hypotension and altered consciousness, suggesting septic shock.

Q10. What is the significance of weight loss in a surgical history? A: Unintentional weight loss >5% over 3-6 months is a red flag for malignancy. It is associated with colon cancer (right-sided with anaemia), gastric cancer (anorexia, early satiety), pancreatic cancer (painless jaundice, weight loss), and lymphoma. It should always prompt further investigation.

Q11. What is absolute constipation and what does it imply? A: No passage of either flatus or faeces. This is a cardinal sign of complete mechanical bowel obstruction, implying no gas is passing beyond the obstruction. It must be differentiated from obstipation (no faeces but flatus may pass = incomplete obstruction or ileus).

Q12. How do you assess fitness for anaesthesia from the history? A: Systematic enquiry into cardiorespiratory status: exercise tolerance (MET - metabolic equivalents), dyspnoea, angina, previous MI (timing matters - avoid surgery <3-6 months post-MI), arrhythmias, COPD, OSA, bleeding disorders, previous anaesthetic complications. The ASA classification is based largely on the history.

Advanced / Exam Level

Q13. A patient with acute epigastric pain denies cardiac history. What drug history finding might suggest otherwise? A: Finding the patient is on antihypertensives, statins, nitrates, beta-blockers, or anti-anginals would indicate treated cardiac disease. Inferior MI can present as epigastric pain. An ECG and troponin are mandatory.

Q14. How does the history differentiate organic from functional bowel disease? A: Features favouring organic disease: recent onset, progressive symptoms, nocturnal symptoms (waking from sleep), blood/mucus in stool, unintentional weight loss, family history of colorectal cancer, age >50 with new symptoms. Features favouring IBS (functional): longstanding, episodic, related to stress, left-sided pain relieved by defecation, bloating, alternating bowel habit, no red flags.

Q15. What is the surgical significance of the oral contraceptive pill? A: OCP increases risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) perioperatively by inducing a hypercoagulable state (increased clotting factors, decreased antithrombin). Risk-benefit assessment is required; consideration should be given to stopping OCP 4-6 weeks before elective major surgery if thromboprophylaxis cannot be fully assured.

Q16. Why is industrial history important in surgical clerking? A: Occupational exposures cause specific malignancies: asbestos → mesothelioma and lung cancer; aniline dyes / rubber industry → transitional cell carcinoma of the bladder; radiation exposure → thyroid/haematological malignancy. Occupation may also explain hernia development (heavy manual work).

Q17. A 70-year-old man presents with painless jaundice and weight loss. What history findings would point to pancreatic cancer vs choledocholithiasis? A: Pancreatic cancer: insidious onset, progressive, painless jaundice with weight loss, anorexia, pale stools + dark urine, possible new-onset diabetes mellitus, no biliary colic history, Courvoisier's sign possible. Choledocholithiasis: previous biliary colic history, episodic jaundice, associated RUQ pain, fever (cholangitis), younger patients, often not painless.

Q18. How does the social history influence surgical decision-making? A: Smoking increases anaesthetic and respiratory complications, wound infection, and anastomotic leak risk. Alcohol excess indicates hepatic dysfunction (coagulopathy, poor healing, alcohol withdrawal risk - Wernicke's, delirium tremens). Domestic circumstances determine feasibility of day-case surgery and post-operative recovery at home. Social isolation may require convalescent placement.

Q19. What are the red flag symptoms in a surgical history that mandate urgent investigation? A: Unintentional weight loss, dysphagia, haematemesis, melaena, fresh PR bleeding in >40 years, change in bowel habit >6 weeks, palpable abdominal/rectal mass, iron-deficiency anaemia, obstructive jaundice, persistent vomiting.

Q20. You are clerking a patient for an emergency laparotomy. What are the most critical history items to establish urgently? A: (1) Time of last oral intake (aspiration risk - full stomach protocol); (2) Allergy history (contrast, penicillin, latex); (3) Current anticoagulants/antiplatelets (reversal may be needed); (4) Significant cardiac/respiratory comorbidities; (5) Previous similar episodes or operations; (6) Drug history for steroid cover, insulin management; (7) Pregnancy status (females of reproductive age); (8) Bleeding history/disorders.

Summary Table: Components of a Surgical History

Component	Key Points
PC	Onset, duration, character, SOCRATES for pain
PMH	Previous surgery, similar episodes, comorbidities, MI timing
DHx	Anticoagulants, steroids, beta-blockers, OCP, allergies
SHx	Smoking, alcohol, occupation, domestic support
FHx	Cancer, IBD, bleeding disorders, anaesthetic reactions
Systems Review	Cardiorespiratory fitness, GI, urological, gynaecological

Sources: Bailey & Love's Short Practice of Surgery 28th Edition, pp. 1073-1074; Pye's Surgical Handicraft 22nd Edition, pp. 112-115

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Recent Literature: Diagnostic Accuracy of Clinical History in General Surgery

Literature search: PubMed, 2019-2026. Evidence tiers follow the Cochrane hierarchy.

Overview

The central question - how much diagnostic weight should be assigned to clinical history and symptoms alone, versus composite clinical scores, versus investigation findings - has been addressed directly by a coherent body of recent literature, primarily from the Eskelinen group (Finland) and a landmark 2025 meta-analysis on appendicitis scoring systems.

The consistent finding across conditions is: clinical history/symptoms alone have moderate diagnostic accuracy (AUC ~0.54-0.66), but structured clinical decision scores incorporating history + signs + tests achieve excellent accuracy (AUC ~0.87-0.98). History alone is insufficient to rule in or rule out most surgical conditions; it must be integrated into a scoring framework.

1. Acute Appendicitis - Clinical Scoring Systems

[Systematic Review + Meta-Analysis . Tier 1 . 2025]

Alvarez-Lozada LA et al. "Clinical scores for acute appendicitis in adults: A systematic review and meta-analysis of diagnostic accuracy studies." American Journal of Surgery. 2025 Feb. PMID: 39667296

Key findings:

Included 40 studies comparing clinical scoring systems against histopathological confirmation
The RIPASA score showed superior performance: sensitivity 0.93 (95% CI 0.78-0.98), specificity 0.81 (95% CI 0.62-0.91), DOR 45.3, AUC = 0.913
RIPASA was significantly better than both the Alvarado (p < 0.002) and Modified Alvarado scores (p < 0.004)
The Alvarado score, though most studied, does not have the highest diagnostic accuracy
Many other scores surpass the Alvarado in head-to-head comparisons

Surgical relevance: Clinical history items (migration of pain, anorexia, nausea/vomiting) are explicit components of the RIPASA and Alvarado scores. History items alone cannot approach the 0.93 sensitivity achieved by the composite score. This directly supports the practice of structured clinical scoring over unstructured history-taking.

2. Acute Small Bowel Obstruction - Diagnostic Score vs. History Alone

[Meta-Analysis . Tier 2 . 2021]

Eskelinen M et al. "A Diagnostic Score for Acute Small Bowel Obstruction." Anticancer Research. 2021 Apr. PMID: 33813402

Key findings (n = 1,333 AAP patients; 54 ASBO cases):

Diagnostic Modality	AUC (SROC)	95% CI
Clinical history-taking alone	0.638	0.600-0.676
Diagnostic findings + tests	0.694	0.630-0.724
Diagnostic score (without pain location)	0.962	0.940-0.986
Diagnostic score (with pain location)	0.971	0.952-0.988

History vs. findings: no significant difference (p = 0.312)
Both were vastly inferior to composite diagnostic scores (p < 0.0001)
The diagnostic score achieved near-perfect discrimination without radiological input

Implication: For ASBO, history-taking alone provides only moderate discriminative ability (AUC 0.638). Its value is realised when combined into a structured score.

3. Acute Appendicitis in Elderly Patients

[Cohort study . 2021]

Eskelinen M et al. "A Diagnostic Score Is a Powerful Tool in Diagnosis of Acute Appendicitis in Elderly Patients." Anticancer Research. 2021 Mar. PMID: 33788738

Key findings (n = 470 patients >50 years):

Modality	AUC
Symptoms (history-taking)	0.658
Signs + tests	0.751
Diagnostic score (without temp)	0.977
Diagnostic score (with temp)	0.980

In elderly patients, clinical presentation of appendicitis is atypical - history-taking is less reliable (AUC 0.658 vs. 0.751 for signs)
Signs + tests significantly outperformed history alone (p = 0.036)
Composite diagnostic score was overwhelmingly superior (p < 0.0001)

Surgical relevance: Elderly patients present atypically - they may lack classic migratory pain, have blunted fever responses, and give unreliable histories due to cognitive impairment. This explains the relatively lower AUC for history alone in this cohort.

4. Acute Cholecystitis

[Cohort study . 2020]

Eskelinen M et al. "Performance of a Diagnostic Score in Confirming Acute Cholecystitis Among Patients With Acute Abdominal Pain." Anticancer Research. 2020 Dec. PMID: 33288589

Key findings (n = 1,333 patients):

Modality	AUC
Clinical history + symptoms	0.542
Signs + laboratory tests	0.580
Diagnostic score	0.962

History alone for cholecystitis: AUC only 0.542 - barely above chance
No significant difference between history and signs+tests (p not significant)
Both were vastly inferior to the composite DS (p = 0.0001)

Implication: Isolated history-taking has essentially no standalone diagnostic utility for acute cholecystitis. This highlights why investigations (ultrasound, LFTs, WBC) are indispensable.

5. Acute Pancreatitis

[Cohort study . 2022]

Eskelinen M et al. "A Simple Prediction Score for Diagnosis of Acute Pancreatitis." In Vivo. 2022 Sep-Oct. PMID: 36099125

Key findings:

Modality	AUC	95% CI
Clinical history-taking	0.640	0.550-0.730
Clinical signs + tests	0.588	0.520-0.656
Diagnostic score	0.943	0.910-0.976

Notably, history-taking outperformed signs + tests for pancreatitis (p = 0.155, not significant)
Composite DS dramatically outperformed both (p < 0.0001)
The history is the single most informative component for pancreatitis (sudden-onset severe epigastric pain + alcohol or gallstone history)

6. Non-Specific Abdominal Pain (NSAP)

[Cohort study . 2021]

Eskelinen M et al. "A Diagnostic Score in the Difficult Diagnosis of Non-specific Abdominal Pain." In Vivo. 2021. PMID: 34410962

Modality	AUC
Symptoms	0.542
Signs + tests	0.625
Diagnostic score	0.874

Even for NSAP (a "diagnosis of exclusion"), symptoms alone are near-chance (0.542)
A structured score raises discrimination to 0.874

7. Non-Organic Dyspepsia

[Cohort study . 2021]

Eskelinen M et al. "History-taking, Clinical Signs, Tests and Scores for Detection of Non-organic Dyspepsia Among Patients With Acute Abdominal Pain." Cancer Diagnosis & Prognosis. 2021. PMID: 35403135

Modality	AUC
Symptoms	0.608
Signs + tests	0.621
Diagnostic score	0.877

No significant difference between history and signs (p = 0.715) - both are modest
DS without radiology or endoscopy achieves excellent accuracy

8. Acute Abdominal Pain in Elderly Patients - Systematic Review

[Systematic Review . Tier 1 . 2020]

Sangiorgio G et al. "Acute abdominal pain in older adults: a clinical and diagnostic challenge." Minerva Chirurgica. 2020 Jun. PMID: 32550726

Key conclusions:

Delayed presentation, altered lab parameters, polypharmacy, cognitive impairment, and absence of accurate medical history all make diagnosis difficult in the elderly
Both mortality and surgical rates increase with age
A systematic, category-based differential diagnosis using history + examination + imaging is the recommended approach
Prompt radiological investigation is essential - history alone is insufficient in elderly surgical patients

9. Pain Onset Characterisation - A 2026 Prospective Study

[Prospective diagnostic study . 2026]

Takada T et al. "Diagnostic Performance of Onset Characterization vs. Time-to-Peak Assessment in Acute Abdominal Pain." Journal of General Internal Medicine. 2026 Jun. PMID: 41361042

Study details: 629 consecutive ED patients; target condition = rupture, dissection, vascular occlusion, torsion, or perforation (n = 20, 3.2%)

History Question Method	Sensitivity	Specificity
"Was the pain sudden?" (sudden onset characterisation)	40.0% (95% CI 21.9-61.3%)	86.7% (95% CI 83.8-89.2%)
"How long to peak?" instantaneous = positive (time-to-peak)	30.0% (95% CI 14.5-51.9%)	94.3% (95% CI 92.1-95.8%, p < 0.001)

Key insight: Time-to-peak assessment achieves significantly higher specificity (94.3%) than simple "sudden onset" questioning (86.7%) without losing sensitivity. Neither method alone rules out life-threatening conditions (low sensitivity for both).

Practical implication: Asking "How quickly did the pain reach its worst?" (instantaneous = positive) is a more specific history-taking question than simply asking if pain was "sudden." This refinement in how pain onset is characterised during history-taking has measurable impact on diagnostic performance.

Synthesis: What the Evidence Tells Us

Diagnostic Accuracy of History Alone - Summary Table

Condition	History-Only AUC	With Composite Score AUC	Gain
Small bowel obstruction	0.638	0.971	+0.333
Acute cholecystitis	0.542	0.962	+0.420
Acute pancreatitis	0.640	0.943	+0.303
Non-specific abdominal pain	0.542	0.874	+0.332
Non-organic dyspepsia	0.608	0.877	+0.269
Appendicitis (elderly)	0.658	0.980	+0.322
Appendicitis (all adults - RIPASA)	-	AUC 0.913, Se 93%, Sp 81%	-

AUC < 0.70 = poor; 0.70-0.79 = acceptable; 0.80-0.89 = excellent; ≥ 0.90 = outstanding

Key Takeaways

History alone is consistently insufficient for diagnosis in surgical conditions - AUC ranges from 0.54-0.66, which is poor to moderate.
Structured scoring systems combining history items with clinical signs and basic tests achieve AUC of 0.87-0.98, which is excellent to outstanding.
The Eskelinen group's work on a cohort of 1,333 AAP patients is the most systematic contemporary dataset quantifying history-taking accuracy across multiple surgical diagnoses. Their finding that history and examination separately are not significantly different in many conditions (both poor) is sobering.
Appendicitis scoring (RIPASA) shows the highest diagnostic performance among clinical scores, but relies on history items as key inputs - the value of history is unlocked through structured use.
Pain characterisation technique matters (Takada 2026): asking about time-to-peak is more specific (94.3%) than asking about sudden onset (86.7%) for detecting life-threatening abdominal conditions.
Elderly patients are a special challenge: history-taking is less reliable than even the general population (atypical presentation, cognitive impairment), necessitating early imaging.
Despite these limitations, a careful history remains the foundation on which all else is built - it directs examination, determines urgency, and selects appropriate investigations.

Clinical Scoring Systems Referenced

Score	Condition	Components
RIPASA	Appendicitis	Age, sex, RIF pain, migration, anorexia, nausea/vomiting, duration, RIF tenderness, guarding, rebound, Rovsing's sign, fever, raised WBC, urinalysis
Alvarado (MANTRELS)	Appendicitis	Migration, anorexia, nausea, RIF tenderness, rebound, elevated temp, WBC leucocytosis, left shift
Modified Alvarado	Appendicitis	Same minus left shift
Tokyo Guidelines	Cholecystitis	Murphy's sign, fever, RUQ pain, WBC, CRP, imaging
Ranson's Criteria	Pancreatitis	On admission (history + labs) + at 48h

Sources: PubMed search, June 2026. PMIDs: 39667296, 33813402, 33788738, 33288589, 36099125, 34410962, 35403135, 32550726, 41361042

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