Sandbox:Javaria

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 Associated pain: ❑ Site (eg, a particular quadrant or diffuse, a change in location may reflect progression of the disease ❑ 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 ❑ Altered mental status ❑ Nausea & vomiting ❑ Diaphoresis ❑ Fever ❑ Hematuria ❑ Anorexia ❑ Bloody stool ❑ Weight loss ❑ Vaginal discharge ❑ Penile discharge ❑ Jaundice ❑ Mal-digestion ❑ Flatulence ❑ 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 ❑ 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 different types of cancers, eg. cancer bladder, which may cause abdominal pain) ❑ Occupational history (exposure to chemicals or toxins) ❑ Travel history ❑ Medications (for over the counter drugs as

Examine the patient: ❑ Vital signs ❑ Temperature ❑ Heart rate (tachycardia) ❑ Blood pressure (hypotension) ❑ Respiratory rate (tachypnea) ❑ Skin ❑ Diaphoresis ❑ 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) ❑ Signs of sepsis: tachycardia, decreased urination, and hyperglycemia, confusion, metabolic acidosis with compensatory respiratory alkalosis, hypotension, decreased systemic vascular resistance, and coagulation dysfunctions

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 ❑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) 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

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

Table illustrates common imaging findings in particular disease.

Cause of abdominal mass	CT scan	Ultrasound	MRI	PET scan
Hepatic cyst	Reserved for more complicated cases. For more information click here	Most useful initial test. Assess cyst size, type, location within the liver, type, and anatomic relations with surroundings.
Hemangiomas	Asymmetric peripheral enhancement on IV contrast (diagnostic potential)
Hepatic adenomas	Well-circumscribed hypo-intense lesions.
Hepatocellular carcinoma	Diffuse enhancement with arterial phase contrast, and then washout during delayed venous images.
Focal nodular hyperplasia	Well-circumscribed mass with central stellate scar. With IV contrast hyperintense on arterial phase and isodense on venous phase.
Cholangiocarcinoma	Lesion occurs in the periphery of liver Primary staging: Higher Sn in detecting extrahepatic invasion and vascular involvement.		Modality of choice for diagnosis and staging Contrast enhancement patterns vary based on tumour size, composition and structure