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 | | | | | | | |
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| | | | | | | | | | | | | | Associated pain | | | | | | |
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| | | | | | | Reducible mass ❑ Suspect hernia❑ Thorough history, past surgical history, and physical exam (lying down and standing) | | | | | | | | | | | | | | |
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| | | | | | | Abdominal USElective repair | | | | | | | | | | | | | |
| | | | | | | | | | | | | Characterise the pain
- ❑ Site (eg, a particular quadrant or diffuse
- ❑ Onset (eg, sudden, gradual)
- ❑ Quality (eg, dull, sharp, colicky, waxing and waning)
- ❑ Aggravating and relieving factors (e.g, Is the pain related to your meals?)
- ❑ Intensity (scale of 0-10/ 0-5 with the maximum number; 10/5 being the worst pain of life)
- ❑ Time course (eg, hours versus weeks, constant or intermittent)
- ❑ Radiation (eg, to the shoulder, back, flank, groin, or chest)
Associated symptoms
- ❑ Shortness of breath (decreased oxygen carrying capacity due to splenic dysfunction)
- ❑ Altered mental status
- ❑ Nausea & vomiting
- ❑ Diaphoresis
- ❑ Fever
- ❑ Hematuria
- ❑ Anorexia
- ❑ Bloody stool
- ❑ Weight loss
- ❑ Jaundice
- ❑ Fatigue
- ❑ Recent trauma
- ❑ Symptoms suggestive of sepsis
Detailed history:
- ❑ Age (Patients above 50 years old are more likely to have severe diseases or cancers, such as ruptured abdominal aortic aneurysm or colon cancer)
- ❑ Past medical history (Hep B, hep C, NASH, alcoholic hep all predispose to HCC)
- ❑ Past surgical history (for previous abdominal surgeries)
- ❑ Menstrual and contraceptive history (pregnancy should be excluded in all women of childbearing age with abdominal mass)
- ❑ Social history (alcohol abuse predispose to pancreatitis and hepatitis, smoking also predisposes to AAA and cancers, e.g. bladder cancer)
- ❑ Occupational history (exposure to chemicals or toxins)
- ❑ Travel history (recent foreign travel/ drinking of unfiltered water increases risk for echinococcus or entamoeba infection).
- ❑ Family history (polycystic kidney disease
- ❑ Medications (30 and 50 years old women with longstanding OCP use, may suspect hepatic adenoma
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| | | | | | | | | | | | | Examine the patient:
❑ Vital signs
- ❑ Temperature (fever may point to abscess or other infectious causes of mass
- ❑ Heart rate (tachycardia)
- ❑ Blood pressure (hypotension)
- ❑ Respiratory rate (tachypnea)
❑ Skin
- ❑ petechiae/ecchymoses/bleeding (may be associated with splenomegaly or hepatomegaly
- ❑ Pallor
- ❑ Jaundice
- ❑ Dehydration
❑ Inspection
- ❑ If the patient is lying still in bed with knees bent, this is suggestive of organ rupture and resulting peritonitis
- ❑ Signs of previous surgery
- ❑ Abdominal pulsations
- ❑ Signs of systemic disease e.g.
- ❑ Pallor, suggestive of bleeding
- ❑ Spider angiomata, suggestive of cirrhosis
❑ Auscultation
- ❑ Abdominal crepitations
- ❑ Reduced bowel sounds
- ❑ Bruit, suggestive of abdominal aortic aneurysm
❑ Palpation
- ❑ Rigidity
- ❑ Guarding
- ❑ Abdominal tenderness
- ❑ Distension
- ❑ Detection of masses on palpating the abdomen
- ❑ Carnett's sign
❑ Pelvic exam in females / testicular examination in males
❑ Cardiovascular system
❑ Respiratory system
❑ Anorectal bleeding (maybe due to CRC or IBD)
❑ Signs of sepsis: tachycardia, decreased urination, and hyperglycemia, confusion, metabolic acidosis with compensatory respiratory alkalosis, hypotension, decreased systemic vascular resistance, and coagulation dysfunctions
Signs of peritonitis or shock ❑ fever, abdominal tenderness, guarding, rebound tenderness, rigidity, confusion, hypotension , and low urine output
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| | | | | | | | | 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 | | | | | Patient is stable | | | | | | |
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| | | | | | | | | | | | | Order laboratory tests: ❑ Pregnancy test (required in women of child-bearing age)
❑ CBC, Hematocrit (thrombocytopenia, leukopenia, anemia may be associated with splenomegaly)
❑ Urinalysis ❑ ESR❑ ABG ❑ D dimer❑ Serum lactate ❑ BMP ( urea, creatinine, serum electrolytes, BSL) ❑ Amylase ❑ Lipase ❑ Triglyceride ❑ Liver function tests (total bilirubin, direct bilirubin, albumin, AST, ALT, Alkaline phosphatase, GGT) | | | | | | | | | |
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| | | | | | | | | | | | | Order imaging studies: ❑ Order urgent trans abdominal ultrasound (TAUSG) ❑ Abdominal CT ❑ ECG ❑ MRCP ❑ Abdominal x-ray ❑ Angiography ❑ Diagnostic paracentesis
*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 | | | | | | | | | | |
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| | | | | | No | | | | | | | | | | | | | Yes | | | | | | | |
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