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

Patient presents with abdominal mass

No associated pain 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

Associated pain

Reducible mass ❑ Suspect hernia ❑ Thorough history, past surgical history, and physical exam (lying down and standing)

Abdominal US Elective 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

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

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

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)

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

No

Yes