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| <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>
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| {{familytree/start |summary=Acute abdominal pain}}
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| {{familytree | | | | | | | | | | | | | | Z01 | | | | | | | |Z01=Patient presents with abdominal mass}}
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| {{familytree | | | | | | | | | | | | | |,|^|.| | | | | | |}}
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| {{familytree | | | | | | | | |,|-|-| Y01 | |Y02 | | | | | | |Y01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''No associated pain''' <br>[[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|Y02='''Associated pain'''}}
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| {{familytree | | | | | | | | X01 | | | |`|v|'| | | | | | |X01=<div style="float: left; text-align: left; width: 20em; padding:1em;">Reducible mass<br>❑ Suspect [[hernia]]<br>❑ Thorough history, past surgical history, and physical exam (lying down and standing)}}
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| {{familytree | | | | | | | | |!| | | | | |!| | | | | | | |}}
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| {{familytree | | | | | | | | W01 | | | | |!| | | | | | | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;">Abdominal [[US]]<br>Elective repair}}
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| {{familytree | | | | | | | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterise the pain'''<br>
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| :❑ Site (eg, a particular quadrant or diffuse
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| :❑ Onset (eg, sudden, gradual)
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| :❑ Quality (eg, dull, sharp, colicky, waxing and waning)
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| :❑ Aggravating and relieving factors (e.g, Is the pain related to your meals?)
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| :❑ Intensity (scale of 0-10/ 0-5 with the maximum number; 10/5 being the worst pain of life)
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| :❑ Time course (eg, hours versus weeks, constant or intermittent)
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| :❑ Radiation (eg, to the shoulder, back, flank, groin, or chest)<br>
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| '''Associated [[symptoms]]'''<br>
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| :❑ [[Shortness of breath]] (decreased oxygen carrying capacity due to splenic dysfunction)
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| :❑ [[Altered mental status]]
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| :❑ [[Nausea]] & [[vomiting]]
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| :❑ [[Diaphoresis]]
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| :❑ [[Fever]]
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| :❑ [[Hematuria]]
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| :❑ [[Anorexia]]
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| :❑ [[Bloody stool]]
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| :❑ [[Weight loss]]
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| :❑ [[Jaundice]]
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| :❑ [[Fatigue]]
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| :❑ Recent [[trauma]]
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| :❑ Symptoms suggestive of [[Sepsis history and symptoms|sepsis]]
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| '''Detailed history:'''<br>
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| :❑ Age (Patients above 50 years old are more likely to have severe diseases or cancers, such as ruptured [[abdominal aortic aneurysm]] or [[colon cancer]])
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| :❑ Past medical history ([[Hepatitis B|Hep B]], [[Hepatitis C|hep C]], [[NASH]], [[Alcoholic Hepatitis|alcoholic hep]] all predispose to [[HCC]])
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| :❑ Past surgical history (for previous abdominal surgeries)
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| :❑ Menstrual and contraceptive history (pregnancy should be excluded in all women of childbearing age with abdominal mass)
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| :❑ Social history (alcohol abuse predispose to [[pancreatitis]] and [[hepatitis]], smoking also predisposes to [[AAA]] and [[cancer]]s, e.g. [[bladder cancer]])
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| :❑ Occupational history (exposure to chemicals or toxins)
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| :❑ Travel history (recent foreign travel/ drinking of unfiltered water increases risk for [[echinococcus]] or [[entamoeba]] infection).
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| :❑ Family history ([[polycystic kidney disease]]
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| :❑ Medications (30 and 50 years old women with longstanding [[OCP]] use, may suspect [[hepatic adenoma]]</div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:''' <br>
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| ❑ Vital signs<br>
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| :❑ [[Temperature]] ([[fever]] may point to [[abscess]] or other infectious causes of mass<br>
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| :❑ [[Heart rate]] ([[tachycardia]]) <br>
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| :❑ [[Blood pressure]] ([[hypotension]])<br>
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| :❑ [[Respiratory rate]] ([[tachypnea]])<br>
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| ❑ Skin <br>
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| :❑ [[petechiae]]/[[ecchymoses]]/[[bleeding]] (may be associated with [[splenomegaly]] or [[hepatomegaly]]
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| :❑ [[Pallor]]
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| :❑ [[Jaundice]]
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| :❑ [[Dehydration]]
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| ❑ Inspection <br>
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| :❑ If the patient is lying still in bed with knees bent, this is suggestive of organ rupture and resulting [[peritonitis]]<br>
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| :❑ Signs of previous surgery<br>
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| :❑ Abdominal pulsations<br>
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| :❑ Signs of systemic disease e.g.<br>
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| ::❑ [[Pallor]], suggestive of bleeding<br>
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| ::❑ [[Spider angiomata]], suggestive of [[cirrhosis]]<br>
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| ❑ [[Auscultation]] <br>
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| :❑ Abdominal crepitations<br>
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| :❑ Reduced bowel sounds<br>
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| :❑ Bruit, suggestive of [[abdominal aortic aneurysm]]<br>
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| ❑ Palpation<br>
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| :❑ Rigidity
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| :❑ [[Guarding]]
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| :❑ Abdominal tenderness
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| :❑ [[Distension]]
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| :❑ Detection of masses on palpating the abdomen
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| :❑ [[Carnett's sign]]
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| ❑ [[Pelvic exam]] in females / [[testicular examination]] in males<br>
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| ❑ [[Cardiovascular system]]<br>
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| ❑ [[Respiratory system]]<br>
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| ❑ Anorectal [[bleeding]] (maybe due to [[colorectal cancer|CRC]] or [[IBD]])<br>
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| ❑ [[Signs of sepsis]]: [[tachycardia]], decreased urination, and [[hyperglycemia]], [[confusion]], [[metabolic acidosis]] with compensatory [[respiratory alkalosis]], [[hypotension]], decreased [[systemic vascular resistance]], and [[coagulation]] dysfunctions<br>
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| '''Signs of [[peritonitis]] or [[shock]]'''<br> ❑ [[fever]], abdominal [[tenderness]], [[guarding]], [[rebound tenderness]], [[rigidity]], [[confusion]], [[hypotension]] , and low [[urine output]]
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| </div>}}
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| {{familytree | | | | | | | | | | |,|-|-|-|^|-|-|.| | | | }}
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| {{familytree | | | | | | | | | | W01 | | | | | W02 | | | | | | |W01=<div style="float: left; text-align: left; line-height: 150% ">'''Patient is unstable,''' <br> '''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>|W02='''Patient is stable'''}}
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| {{familytree | | | | | | | | | | |`|-|-|-|v|-|'| | | | | }}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | }}
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| {{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>
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| ❑ [[CBC]], [[Hematocrit]] ([[thrombocytopenia]], [[leukopenia]], [[anemia]] may be associated with [[splenomegaly]])<br>
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| ❑ [[Urinalysis]]<br> ❑[[ESR]]<br>❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br> ❑ [[BMP]] ([[urea]], [[creatinine]], [[serum electrolytes]], [[BSL]]) <br> ❑ [[Amylase]] <br> ❑ [[Lipase]] <br> ❑ [[Triglyceride]] <br>❑[[Liver function tests]] (total [[bilirubin]], direct [[bilirubin]], [[albumin]], [[AST]], [[ALT]], [[Alkaline phosphatase]], [[GGT]]) }}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | Z02 | | | | | | | | |Z02=}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | Z01 | | | | | | | | | | |Z01 ='''Order imaging studies:''' <br> ❑ Order urgent trans abdominal [[ultrasound]] (TAUSG)<br> ❑ [[Abdominal CT]]<br> ❑ [[ECG]]<br> ❑ [[MRCP]] <br> ❑ [[Abdominal x-ray]] <br> ❑ [[Angiography]]<br> ❑ Diagnostic [[paracentesis]]<br>
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| ----
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| '''''*Order the tests to rule in a suspected diagnosis<br> or to assess a case of unclear etiology'''''<br> '''''*In case of elderly patients, immunocompromised<br> or those unable to provide a comprehensive<br> history, order broader range of tests''''' </div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | A01 | | | | | |A01=}}
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| {{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
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| {{familytree | | | | | | | C01 |-|-|-|-|-|.| | | | | | C03 | | | | | | | |C01=No|C02=No|C03=Yes}}
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| {{familytree | | | | | | | |!| | | | | | |!| | | | | | |!| }}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
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| {{familytree/end}}
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