Sandbox:Javaria: Difference between revisions
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{{familytree/start |summary=PE diagnosis Algorithm.}} | |||
{{familytree | | | | | | | | A01 |A01= '''Pulsatile abdominal mass'''<ref name="pmid22470694">{{cite journal |vauthors=Moussa O, Al Samaraee A, Ray R, Nice C, Bhattacharya V |title=A Tender Pulsatile Epigastric Mass is NOT Always an Abdominal Aortic Aneurysm: A Case Report and Review of Literature |journal=J Radiol Case Rep |volume=4 |issue=10 |pages=26–31 |date=2010 |pmid=22470694 |pmc=3303349 |doi=10.3941/jrcr.v4i10.458 |url=}}</ref><ref>{{cite book | last = Starnes | first = Benjamin | title = Ruptured abdominal aortic aneurysm : the definitive manual | publisher = Springer | location = Cham | year = 2017 | isbn = 9783319238449 }}</ref><br>History (such as associated pain, past medical, surgical history) and physical exam (such as location and extent of the mass, change in size) <br>Risk factors for the development of [[AAA]]}} | |||
{{familytree | | | | | | | | |!| | | | | | }} | |||
{{familytree | | | | | | | | D01| | | | | |D01=Assess hemodynamic stability }} | |||
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }} | |||
{{familytree | | | B01 | | | | | | | | B02 | | |B01= Unsable|B02= Stable}} | |||
{{familytree | | | |!| | | | | | | | | |!| }} | |||
{{familytree | | | C01 | | | | | | | | |!| |C01=<div style="float: left; text-align: left; line-height: 150% ">❑Airway, Breathing and Circulation (ABC)<br>❑Clinical diagnosis of ruptured [[AAA]] considered if age >50 years, abdominal/back pain and [[hypotension]] <br>❑[[Systolic blood pressure|Systolic BP]] >70 acceptable (permissive hypotension)}} | |||
{{familytree | | | |!| | | | | | | | | |!| }} | |||
{{familytree | | | D01 |-| D03 | | | | |!|D01=❑Emergency repair (open or endovascular) if expertise are available|D03=❑Transfer to a facility with vascular specialist expertise}} | |||
{{familytree | | | | | | | | | | | | | |!| }} | |||
{{familytree | | | | | | | | | | | | | G01 | |G01=<div style="float: left; text-align: left; line-height: 150% "> ❑Abdominal [[ultrasound|US]]/ [[CT]] scan<br>❑[[CT angiography]] (gold standard for evaluation of [[AAA]])<br> | |||
:❑Ruptured [[AAA]] | |||
Contrast extravasation, draped aorta sign, and [[retroperitoneal]] [[hematoma]] with perirenal and pararenal space extension. | |||
:❑Unruptured [[AAA]] | |||
Hyperattenuating crescent sign, >150% normal diameter of [[aorta]], [[mural thrombus]] and [[calcification]]}} | |||
{{familytree | | | | | | | | | | | | | |!| }} | |||
{{familytree | | | | | | | | | |,|-|-|-|^|.| }} | |||
{{familytree | | | | | | | | | E01 | | E02 |E01=No [[AAA]]|E02=[[AAA]] found}} | |||
{{familytree | | | | | | | | | |!| | | |!| }} | |||
{{familytree | | | | | | | | | F01 | | |!| F01=<div style="float: left; text-align: left; line-height: 150% ">Other possible causes as visualised on [[CT]] scan<br> | |||
❑[[Heart failure]] ([[hepatomegaly]], [[portal hypertension]], [[pulmonary edema]], and contrast reflux into [[IVC]] and [[hepatic veins]])<br> | |||
❑Colonic diverticula with peri-colic inflammation and fluid collection<br> | |||
❑Dilatation of renal pelvicalyceal systems, [[splenomegaly]]<br> | |||
❑Tumors (distinct mass or diffuse organ infiltration, [[LAD]], metastasis to other organs)<br> | |||
❑[[Pancreatic pseudocyst]] (Large cyst/multiple cysts in and around the pancreas with [[calcifications]] maybe, [[splenic vein thrombosis]], and [[pseudoaneurysm]]s of [[splenic artery]], bleeding into a pseudocyst}} | |||
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{{familytree | | | | | | | | | | | |,|-|^|.|}} | |||
{{familytree | | | | | | | | | | | G01 | | G02 |G01=Pain|G02=No pain}} | |||
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Abdominal [[ultrasound|US]] (100% [[sensitivity|Sn]] and [[specificity|Sp]] but visualization among 1-3% [[patients]]). <ref name="urlAbdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org">{{cite web |url=https://radiopaedia.org/articles/abdominal-aortic-aneurysm#:~:text=CT%20angiography%20(CTA)%20is%20considered,arteries%20and%20the%20aortic%20bifurcation. |title=Abdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org |format= |work= |accessdate=}}</ref> |
Revision as of 09:09, 15 August 2020
Shown below is an algorithm summarizing the diagnosis of abdominal mass according the the [...] guidelines.
Abbreviations: ACS: Acute coronary syndrome; AAA: Abdominal aortic aneurysm; RUQ: Right upper quadrant; RLQ: Right lower quadrant; LUQ: Left upper quadrant; LLQ: Left lower quadrant
Abdominal mass | |||||||||||||||||||||||
History and brief physical exam Past medical history | |||||||||||||||||||||||
Hemodynamic instability | Stable | ||||||||||||||||||||||
{{{ ! }}} | {{{ ! }}} | ||||||||||||||||||||||
Characterize the mass:
Associated symptoms
Detailed history:
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Vital signs
❑ Skin
❑ Inspection
❑ Auscultation
❑ Palpation
❑ Psoas sign (suggestive of retrocecal appendix) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider extraabdominal differential diagnosis: ❑ aaaa | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Assess hemodynamic stability | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
If the patient is unstable, Stabilize the patient: ❑ Establish two large-bore intravenous peripheral lines ❑ NPO until the patient is stable ❑ Supportive care (fluids and electrolyes as required) ❑ Place nasogastric tube if there is bleeding, obstruction, significant nausea or vomiting ❑ Place foley catheter to monitor volume status ❑ Cardiac monitoring ❑ Supplemental oxygen as needed ❑ Administer early antibiotics if indicated | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
If the patient is stable, Order laboratory tests: ❑ Pregnancy test (required in women of child-bearing age) ❑ CBC ❑ Hematocrit ❑ Urinalysis ❑ Serum electrolytes ❑ ESR ❑ ABG ❑ D dimer ❑ Serum lactate ❑ BUN ❑ Creatinine ❑ Amylase ❑ Lipase ❑ Triglyceride ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Stool for ova and parasites ❑ C. difficile culture and toxin assay Order imaging studies: *Order the tests to rule in a suspected diagnosis or to assess a case of unclear etiology *In case of elderly patients, immunocompromised or those unable to provide a comprehensive history, order broader range of tests | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Signs of peritonitis or shock ❑ Fever ❑ Abdominal tenderness ❑ Abdominal gaurding ❑ Rebound tenderness (blumberg sign) ❑ Diffuse abdominal rigidity ❑ Confusion ❑ Weakness ❑ Low blood pressure ❑ Decreased urine output ❑ Tachycardia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pulsatile abdominal mass[1][2] History (such as associated pain, past medical, surgical history) and physical exam (such as location and extent of the mass, change in size) Risk factors for the development of AAA | |||||||||||||||||||||||||||||||||||
Assess hemodynamic stability | |||||||||||||||||||||||||||||||||||
Unsable | Stable | ||||||||||||||||||||||||||||||||||
❑Airway, Breathing and Circulation (ABC) ❑Clinical diagnosis of ruptured AAA considered if age >50 years, abdominal/back pain and hypotension ❑Systolic BP >70 acceptable (permissive hypotension) | |||||||||||||||||||||||||||||||||||
❑Emergency repair (open or endovascular) if expertise are available | ❑Transfer to a facility with vascular specialist expertise | ||||||||||||||||||||||||||||||||||
❑Abdominal US/ CT scan ❑CT angiography (gold standard for evaluation of AAA)
Contrast extravasation, draped aorta sign, and retroperitoneal hematoma with perirenal and pararenal space extension.
| |||||||||||||||||||||||||||||||||||
No AAA | AAA found | ||||||||||||||||||||||||||||||||||
Other possible causes as visualised on CT scan ❑Heart failure (hepatomegaly, portal hypertension, pulmonary edema, and contrast reflux into IVC and hepatic veins) | |||||||||||||||||||||||||||||||||||
Pain | No pain | ||||||||||||||||||||||||||||||||||
Abdominal US (100% Sn and Sp but visualization among 1-3% patients). [3]
- ↑ Moussa O, Al Samaraee A, Ray R, Nice C, Bhattacharya V (2010). "A Tender Pulsatile Epigastric Mass is NOT Always an Abdominal Aortic Aneurysm: A Case Report and Review of Literature". J Radiol Case Rep. 4 (10): 26–31. doi:10.3941/jrcr.v4i10.458. PMC 3303349. PMID 22470694.
- ↑ Starnes, Benjamin (2017). Ruptured abdominal aortic aneurysm : the definitive manual. Cham: Springer. ISBN 9783319238449.
- ↑ "Abdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org".