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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>
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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'''|Y02='''Associated pain'''}}
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| {{familytree | | | | | | | | | | | | |!| | |!| | | | | |}}
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| {{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 }}
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| {{familytree | | | | | | | | |!| | |!| | | |!| | | | | |}}
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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>❑ Aggravation on standing or cough and physical exam findings both lying down and standing support diagnosis}}
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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; padding:1em;">
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| ❑'''Characterise the mass'''<br>
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| :❑ Location<br>
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| :❑ Consistency ([[lipoma]] feels rubbery)<br>
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| :❑ Size, margins ([[malignant]] lesions have irregular, hard margins)<br>
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| :❑ Color, fluctuance.<br>
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| ❑'''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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| :❑ [[Weight loss]], [[nausea]] & [[vomiting]], [[anorexia]], [[melena]]<br>
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| [[hematuria]], [[jaundice]], [[fatigue]], [[diaphoresis]], [[fever]], 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]]<br>[[Anticoagulant]] use, suspect [[hematoma]]</div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left; 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 [[infection|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]] (blood loss, hepatic or splenic pathology)
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| :❑ [[Jaundice]] (hepatic or splenic pathology)
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| :❑ [[Dehydration]]
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| ❑ Inspection <br>
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| :❑ A patien lying still with bent knees,is suggestive of [[perforation]] and [[peritonitis]] (such as in [[volvulus]])<br>
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| :❑ Surgical scars<br>
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| :❑ Abdominal pulsations<br>
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| :❑ Signs of systemic disease e.g. [[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 may suggest [[abdominal aortic aneurysm|AAA]]<br>
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| ❑ Palpation<br>
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| :❑ Extreme pain may manifest as: rigidity and [[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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| ❑ [[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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| ❑ To read about signs of sepsis [[Sepsis physical examination|click here]]
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| </div>}}
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| {{familytree | | | | | | | | | | |,|-|-|-|^|-|-|.| | | | }}
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| {{familytree | | | | | | | | | | W01 | | | | | W02 | | | | | | |W01='''Patient is unstable''' <br> |W02='''Patient is stable'''}}
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| {{familytree | | | | | | | | | |!| | | | | | |!| | | | }}
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| {{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>}}
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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]] ([[infection]], [[tuberculosis|TB]])<br>
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| ❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br>
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| ❑ [[BMP]] ([[urea]], [[creatinine]], [[serum electrolytes]], [[BSL]]) <br>
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| ❑ [[Amylase]] (important in pancreatic, hepatic, gastric pathologies)<br>
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| ❑ [[Lipase]] (important in pancreatic, hepatic, gastric pathologies)<br> ❑ [[Triglyceride]] <br>
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| ❑[[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='''[[Abdominal x-ray]] (specially if suspecting bowel perforation)<br>'''[[Ultrasound]]''' (TAUSG) is cases of emergency or routine}}
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| {{familytree | | | | | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|v|-|-|.| |}}
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| {{familytree | | | | | | W01 | | W02 | | W03 | | W04 | | W05 | | W01= [[Strangulated hernia]]| W02=[[Cholecystitis]]|W03=No lesion demonstrated|W04=[[Hematoma]]|W05=[[Volvulus]]}}
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| {{familytree | | | | | | |!| | | |!| | | |!| | | |!| | | |!| |!| | | | | |}}
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| {{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}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | | | | | | | | A01 | | | | | | | | |!| | | | |A01=[[Abdominal CT]]/ [[MRI]]}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | |!| | | }}
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| {{familytree | | | | | | | C01 |-|-|-|.| | | | | | | | C03 |-|'| | | | | |C01=Tumor|C03=Incidentiloma}}
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| {{familytree | | | | | | | |!| | | | |!| | | | | | | | |!| }}
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| {{familytree | | | | | | | M01 | | | M02 | | | | | | | M03 | | M01=Bengn lesion|M02=Malignant|M03=❑24 hr urine/ plasma [[metanephrine]]/ [[catecholamines]]<br>❑Low-dose [[dexamethasone suppression test]]}}
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| {{familytree | | | | | | | |!| | | | |!| | | | | | | | |!| | | |}}
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| {{familytree | | | | | | | H01 | | | H02 | | | | |,|-|-|^|.| | | |H01=Observe/ surgery|H02=Surgery/ chemotherapy/ radiation}}
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| {{familytree | | | | | | | | | | | | | | | | | | K01 | | | K02 | | | | K01=Non-functional|K02=Functional}}
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| {{familytree | | | | | | | | | | | | | | | |,|-|-|^|.| | | |!| | | | |}}
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| {{familytree | | | | | | | | | | | | | | | |!| | | |!| | | J01 | | | | | |J01=Surgery}}
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| {{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}}
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| {{familytree/end}}
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| [[MRCP]] <br> ❑ [[Angiography]]<br>
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