Sandbox:Javaria: Difference between revisions
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<ref name="pmid21250260">{{cite journal |vauthors=Walker HK, Hall WD, Hurst JW, Ferguson CM |title= |journal= |volume= |issue= |pages= |date= |pmid=21250260 |doi= |url=}}</ref><ref name="pmid28685511">{{cite journal |vauthors=Lee JM, Kim MK, Ko SH, Koh JM, Kim BY, Kim SW, Kim SK, Kim HJ, Ryu OH, Park J, Lim JS, Kim SY, Shong YK, Yoo SJ |title=Clinical Guidelines for the Management of Adrenal Incidentaloma |journal=Endocrinol Metab (Seoul) |volume=32 |issue=2 |pages=200–218 |date=June 2017 |pmid=28685511 |pmc=5503865 |doi=10.3803/EnM.2017.32.2.200 |url=}}</ref> | |||
<span style="font-size:85%"> '''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</span> | <span style="font-size:85%"> '''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</span> | ||
{{familytree/start |summary=Acute abdominal pain}} | {{familytree/start |summary=Acute abdominal pain}} | ||
{{familytree | | | | | | | | | | | | | | Z01 | | | | | | | |Z01=Patient presents with abdominal mass}} | {{familytree | | | | | | | | | | | | | | Z01 | | | | | | | |Z01='''Patient presents with abdominal mass'''}} | ||
{{familytree | | | | | | | | | | | | | |,|^|.| | | | | | |}} | {{familytree | | | | | | | | | | | | | |,|^|.| | | | | | |}} | ||
{{familytree | | | | | | | | | | {{familytree | | | | | | | | | | | | Y01 | |Y02 | | | | | | |Y01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''No associated pain'''|Y02='''Associated pain'''}} | ||
{{familytree | | | | | | | | X01 | | | | | {{familytree | | | | | | | | | | | | |!| | |!| | | | | |}} | ||
{{familytree | | | | | | | | |,|-|-| K01 | |!| | | | | | |K01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> Can be [[Hemangiomas]], [[hepatic cyst]], [[pancreatic cyst]]s (also majority of cystic neoplasms), [[Intraductal papillary mucinous neoplasm|IPMN]], pancreatic ductal [[adenocarcinoma]] (PDA), some [[neuroendocrine tumor]]s, [[retroperitoneum|retroperitoneal]] [[sarcoma]], [[lymphoma]]s, [[testicular cancer]], [[colon cancer]] [[hernia]]s }} | |||
{{familytree | | | | | | | | |!| | |!| | | |!| | | | | |}} | |||
{{familytree | | | | | | | | X01 | |`|-|-|v|'| | | | | | |X01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Reducible mass'''<br>❑ Suspect [[hernia]]<br>❑ Aggravation on standing or cough and physical exam findings both lying down and standing support diagnosis}} | |||
{{familytree | | | | | | | | |!| | | | | |!| | | | | | | |}} | {{familytree | | | | | | | | |!| | | | | |!| | | | | | | |}} | ||
{{familytree | | | | | | | | W01 | | | | |!| | | | | | | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;">Abdominal [[US]]<br>Elective repair}} | {{familytree | | | | | | | | W01 | | | | |!| | | | | | | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;">Abdominal [[US]]<br>Elective repair}} | ||
{{familytree | | | | | | | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left | {{familytree | | | | | | | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left; padding:1em;"> | ||
❑'''Characterise the mass'''<br> | |||
:❑ Location<br> | |||
:❑ Consistency ([[lipoma]] feels rubbery)<br> | |||
:❑ Size, margins ([[malignant]] lesions have irregular, hard margins)<br> | |||
:❑ Color, fluctuance.<br> | |||
❑'''Characterise the pain'''<br> | |||
:❑ Site (eg, a particular quadrant or diffuse | :❑ Site (eg, a particular quadrant or diffuse | ||
:❑ Onset (eg, sudden, gradual) | :❑ Onset (eg, sudden, gradual) | ||
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'''Associated [[symptoms]]'''<br> | '''Associated [[symptoms]]'''<br> | ||
:❑ [[Shortness of breath]] (decreased oxygen carrying capacity due to splenic dysfunction) | :❑ [[Shortness of breath]] (decreased oxygen carrying capacity due to splenic dysfunction) | ||
:❑ [[ | :❑ [[Weight loss]], [[nausea]] & [[vomiting]], [[anorexia]], [[melena]]<br> | ||
[[hematuria]], [[jaundice]], [[fatigue]], [[diaphoresis]], [[fever]], recent [[trauma]] | |||
:❑ Symptoms suggestive of [[Sepsis history and symptoms|sepsis]] | :❑ Symptoms suggestive of [[Sepsis history and symptoms|sepsis]] | ||
'''Detailed history:'''<br> | '''Detailed history:'''<br> | ||
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:❑ Travel history (recent foreign travel/ drinking of unfiltered water increases risk for [[echinococcus]] or [[entamoeba]] infection). | :❑ Travel history (recent foreign travel/ drinking of unfiltered water increases risk for [[echinococcus]] or [[entamoeba]] infection). | ||
:❑ Family history ([[polycystic kidney disease]] | :❑ Family history ([[polycystic kidney disease]] | ||
:❑ Medications (30 and 50 years old women with longstanding [[OCP]] use, may suspect [[hepatic adenoma]]</div>}} | :❑ Medications (30 and 50 years old women with longstanding [[OCP]] use, may suspect [[hepatic adenoma]]<br>[[Anticoagulant]] use, suspect [[hematoma]]</div>}} | ||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left | {{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left; padding:1em;"> '''Examine the patient:''' <br> | ||
❑ Vital signs<br> | ❑ Vital signs<br> | ||
:❑ [[Temperature]] ([[fever]] may point to [[abscess]] or other infectious causes of mass<br> | :❑ [[Temperature]] ([[fever]] may point to [[abscess]] or other [[infection|infectious]] causes of mass<br> | ||
:❑ [[Heart rate]] ([[tachycardia]]) <br> | :❑ [[Heart rate]] ([[tachycardia]]) <br> | ||
:❑ [[Blood pressure]] ([[hypotension]])<br> | :❑ [[Blood pressure]] ([[hypotension]])<br> | ||
Line 51: | Line 51: | ||
❑ Skin <br> | ❑ Skin <br> | ||
:❑ [[petechiae]]/[[ecchymoses]]/[[bleeding]] (may be associated with [[splenomegaly]] or [[hepatomegaly]] | :❑ [[petechiae]]/[[ecchymoses]]/[[bleeding]] (may be associated with [[splenomegaly]] or [[hepatomegaly]] | ||
:❑ [[Pallor]] | :❑ [[Pallor]] (blood loss, hepatic or splenic pathology) | ||
:❑ [[Jaundice]] | :❑ [[Jaundice]] (hepatic or splenic pathology) | ||
:❑ [[Dehydration]] | :❑ [[Dehydration]] | ||
❑ Inspection <br> | ❑ Inspection <br> | ||
:❑ | :❑ A patien lying still with bent knees,is suggestive of [[perforation]] and [[peritonitis]] (such as in [[volvulus]])<br> | ||
:❑ | :❑ Surgical scars<br> | ||
:❑ Abdominal pulsations<br> | :❑ Abdominal pulsations<br> | ||
:❑ Signs of systemic disease e.g. | :❑ Signs of systemic disease e.g. [[spider angiomata]], suggestive of [[cirrhosis]]<br> | ||
❑ [[Auscultation]] <br> | ❑ [[Auscultation]] <br> | ||
:❑ Abdominal crepitations<br> | :❑ Abdominal crepitations<br> | ||
:❑ Reduced bowel sounds<br> | :❑ Reduced bowel sounds<br> | ||
:❑ Bruit | :❑ Bruit may suggest [[abdominal aortic aneurysm|AAA]]<br> | ||
❑ Palpation<br> | ❑ Palpation<br> | ||
:❑ | :❑ Extreme pain may manifest as: rigidity and [[guarding]] | ||
: | |||
:❑ Abdominal tenderness | :❑ Abdominal tenderness | ||
:❑ [[Distension]] | :❑ [[Distension]] | ||
:❑ Detection of masses on palpating the abdomen | :❑ Detection of masses on palpating the abdomen | ||
❑ [[Pelvic exam]] in females / [[testicular examination]] in males<br> | ❑ [[Pelvic exam]] in females / [[testicular examination]] in males<br> | ||
❑ [[Cardiovascular system]]<br> | ❑ [[Cardiovascular system]]<br> | ||
❑ [[Respiratory system]]<br> | ❑ [[Respiratory system]]<br> | ||
❑ Anorectal [[bleeding]] (maybe due to [[colorectal cancer|CRC]] or [[IBD]])<br> | ❑ Anorectal [[bleeding]] (maybe due to [[colorectal cancer|CRC]] or [[IBD]])<br> | ||
❑ | ❑ To read about signs of sepsis [[Sepsis physical examination|click here]] | ||
</div>}} | </div>}} | ||
{{familytree | | | | | | | | | | |,|-|-|-|^|-|-|.| | | | }} | {{familytree | | | | | | | | | | |,|-|-|-|^|-|-|.| | | | }} | ||
{{familytree | | | | | | | | | | W01 | | | | | W02 | | | | | | |W01=<div style="float: left; text-align: left; line-height: 150% ">' | {{familytree | | | | | | | | | | W01 | | | | | W02 | | | | | | |W01='''Patient is unstable''' <br> |W02='''Patient is stable'''}} | ||
{{familytree | | | | | | | | | |!| | | | | | |!| | | | }} | |||
{{familytree | | | | | | | | | L01 | | | | | |!| | | | L01=<div style="float: left; text-align: left; line-height: 150% ">''''Stabilize the patient:'''<br> ❑ Establish two large-bore intravenous peripheral lines<br> ❑ [[NPO]] until the patient is stable<br> ❑ Supportive care (fluids and electrolyes as required)<br> ❑ Place nasogastric tube if there is bleeding, obstruction, significant [[nausea]] or [[vomiting]]<br> ❑ Place [[foley catheter]] to monitor volume status<br> ❑ Cardiac monitoring<br> ❑ Supplemental oxygen as needed<br> ❑ Administer early [[antibiotics]] if indicated </div>}} | |||
{{familytree | | | | | | | | | | |`|-|-|-|v|-|'| | | | | }} | {{familytree | | | | | | | | | | |`|-|-|-|v|-|'| | | | | }} | ||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | | | | | | | | |!| | | | | | | }} | ||
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{{familytree | | | | | | | | | | | | | | E01 | | | | | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br> ❑ [[Pregnancy test]] (required in women of child-bearing age) <br> | {{familytree | | | | | | | | | | | | | | E01 | | | | | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br> ❑ [[Pregnancy test]] (required in women of child-bearing age) <br> | ||
❑ [[CBC]], [[Hematocrit]] ([[thrombocytopenia]], [[leukopenia]], [[anemia]] may be associated with [[splenomegaly]])<br> | ❑ [[CBC]], [[Hematocrit]] ([[thrombocytopenia]], [[leukopenia]], [[anemia]] may be associated with [[splenomegaly]])<br> | ||
❑ [[Urinalysis]]<br> ❑[[ESR]] ([[infection]], [[tuberculosis|TB]])<br> | |||
❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br> | |||
❑ [[BMP]] ([[urea]], [[creatinine]], [[serum electrolytes]], [[BSL]]) <br> | |||
❑ [[Amylase]] (important in pancreatic, hepatic, gastric pathologies)<br> | |||
❑ [[Lipase]] (important in pancreatic, hepatic, gastric pathologies)<br> ❑ [[Triglyceride]] <br> | |||
❑[[Liver function tests]] (total [[bilirubin]], direct [[bilirubin]], [[albumin]], [[AST]], [[ALT]], [[Alkaline phosphatase]], [[GGT]]) }} | |||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | {{familytree | | | | | | | | | | | | | | Z02 | | | | | | | | |Z02='''[[Abdominal x-ray]] (specially if suspecting bowel perforation)<br>'''[[Ultrasound]]''' (TAUSG) is cases of emergency or routine}} | ||
{{familytree | | | | | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|v|-|-|.| |}} | |||
{{familytree | | | | | | W01 | | W02 | | W03 | | W04 | | W05 | | W01= [[Strangulated hernia]]| W02=[[Cholecystitis]]|W03=No lesion demonstrated|W04=[[Hematoma]]|W05=[[Volvulus]]}} | |||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}} | {{familytree | | | | | | |!| | | |!| | | |!| | | |!| | | |!| |!| | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | A01 | | | | | |A01=}} | {{familytree | | | | | | V01 | | V02 | | |!| | | V04 | | V05 |!| |V01=Surgery|V02=Conservative approach in acute cases ([[NPO]], [[antibiotics]], [[fluids]]<br> or [[cholecystectomy]] |V04= May require surgery|V05=Emergency surgery}} | ||
{{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }} | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | |}} | ||
{{familytree | | | | | | | C01 |-|-|-|-| | {{familytree | | | | | | | | | | | | | | A01 | | | | | | | | |!| | | | |A01=[[Abdominal CT]]/ [[MRI]]}} | ||
{{familytree | | | | | | | |!| | | | | | |!| | | | | | |!| }} | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | |!| | | }} | ||
{{familytree | | | | | | | C01 |-|-|-|.| | | | | | | | C03 |-|'| | | | | |C01=Tumor|C03=Incidentiloma}} | |||
{{familytree | | | | | | | |!| | | | |!| | | | | | | | |!| }} | |||
{{familytree | | | | | | | M01 | | | M02 | | | | | | | M03 | | M01=Bengn lesion|M02=Malignant|M03=❑24 hr urine/ plasma [[metanephrine]]/ [[catecholamines]]<br>❑Low-dose [[dexamethasone suppression test]]}} | |||
{{familytree | | | | | | | |!| | | | |!| | | | | | | | |!| | | |}} | |||
{{familytree | | | | | | | H01 | | | H02 | | | | |,|-|-|^|.| | | |H01=Observe/ surgery|H02=Surgery/ chemotherapy/ radiation}} | |||
{{familytree | | | | | | | | | | | | | | | | | | K01 | | | K02 | | | | K01=Non-functional|K02=Functional}} | |||
{{familytree | | | | | | | | | | | | | | | |,|-|-|^|.| | | |!| | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | |!| | | J01 | | | | | |J01=Surgery}} | |||
{{familytree | | | | | | | | | | | | | | | I01 | | I02 |-|'| | | |I01='''<4cm'''<br>Two CTs, 6 months apart, D/C follow-up if mass size remains constant|I02='''>4cm'''/ malignancy suspicion<br>Observe if no suspicion of malignancy}} | |||
{{familytree/end}} | {{familytree/end}} | ||
[[MRCP]] <br> ❑ [[Angiography]]<br> |
Revision as of 22:43, 17 August 2020
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
Patient presents with abdominal mass | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No associated pain | Associated pain | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Can be Hemangiomas, hepatic cyst, pancreatic cysts (also majority of cystic neoplasms), IPMN, pancreatic ductal adenocarcinoma (PDA), some neuroendocrine tumors, retroperitoneal sarcoma, lymphomas, testicular cancer, colon cancer hernias | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Reducible mass ❑ Suspect hernia ❑ Aggravation on standing or cough and physical exam findings both lying down and standing support diagnosis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abdominal US Elective repair | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑Characterise the mass
❑Characterise the pain
Associated symptoms
hematuria, jaundice, fatigue, diaphoresis, fever, recent trauma
Detailed history:
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Vital signs
❑ Skin
❑ Inspection
❑ Palpation
❑ Pelvic exam in females / testicular examination in males | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient is unstable | Patient is stable | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
'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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Order laboratory tests: ❑ Pregnancy test (required in women of child-bearing age) ❑ CBC, Hematocrit (thrombocytopenia, leukopenia, anemia may be associated with splenomegaly) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abdominal x-ray (specially if suspecting bowel perforation) Ultrasound (TAUSG) is cases of emergency or routine | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Strangulated hernia | Cholecystitis | No lesion demonstrated | Hematoma | Volvulus | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Surgery | Conservative approach in acute cases (NPO, antibiotics, fluids or cholecystectomy | May require surgery | Emergency surgery | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abdominal CT/ MRI | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tumor | Incidentiloma | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Bengn lesion | Malignant | ❑24 hr urine/ plasma metanephrine/ catecholamines ❑Low-dose dexamethasone suppression test | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Observe/ surgery | Surgery/ chemotherapy/ radiation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Non-functional | Functional | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Surgery | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
<4cm Two CTs, 6 months apart, D/C follow-up if mass size remains constant | >4cm/ malignancy suspicion Observe if no suspicion of malignancy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
- ↑ Walker HK, Hall WD, Hurst JW, Ferguson CM. PMID 21250260. Missing or empty
|title=
(help) - ↑ Lee JM, Kim MK, Ko SH, Koh JM, Kim BY, Kim SW, Kim SK, Kim HJ, Ryu OH, Park J, Lim JS, Kim SY, Shong YK, Yoo SJ (June 2017). "Clinical Guidelines for the Management of Adrenal Incidentaloma". Endocrinol Metab (Seoul). 32 (2): 200–218. doi:10.3803/EnM.2017.32.2.200. PMC 5503865. PMID 28685511.