Diagnosis of Abdominal aortic aneurysm

Abdominal aortic aneurysm Diagnosis: Book Excerpts

• Differential Diagnosis - Abdominal Bruit
• Differential Diagnosis - Carotid Bruits
• Differential Diagnosis - Abdominal Masses
• Differential Diagnosis - Abdominal Guarding
• Differential Diagnosis - Abdominal Masses
• Approach to the Diagnosis - ABDOMINAL MASS, GENERALIZED
• History and physical examination - Abdominal mass
• History and physical examination - Bruits
• History and physical examination - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• Diagnosis - Abdominal aneurysm
• Diagnosis - Femoral and popliteal aneurysms
• History and physical examination - Abdominal mass
• History and physical examination - Bruits
• History and physical examination - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• Differential Overview - Abdominal/Pelvic Mass
• Differential Overview - Carotid Bruit
• Diagnosis - Aneurysm, abdominal
• Diagnosis - Aneurysms, femoral and popliteal
• Diagnosis - aneurysm,ventricular
• Diagnosis - Aneurysm, thoracic aortic
• History - Abdominal mass
• History - Bruits
• Clinical Features and Diagnosis - Abdominal Masses
• History and physical examination - Abdominal mass
• History and physical examination - Bruits
• History and physical examination - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• Approach to the Diagnosis - Abdominal Mass, Generalized

Diagnosis of Abdominal aortic aneurysm: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Abdominal aortic aneurysm:

• AAA linked to inflammatory system
• Aneurysms are often asymptomatic and can rupture unexpectedly
• More news »

Diagnostic Tests for Abdominal aortic aneurysm: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Abdominal aortic aneurysm.

Abdominal Bruit: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Abdominal aortic aneurysm
• Hepatocellular carcinoma (hepatoma)
• Cirrhosis
• Liver hemangioma
• Arteriovenous malformation
• Renal artery stenosis
• Celiac artery stenosis
• Superior mesenteric artery stenosis
• Tricuspid regurgitation
• Turbulence of the splenic artery
• Hepatic venous hum
  –High-pitched continuous murmur that decreases with forced held expiration
• Cruveilhier-Baumgarten murmur
  –High-pitched venous hum of portal hypertension that becomes louder with forced expiration
• Abdominal friction rub
  –Associated with hepatoma, cholangiocarcinoma, liver metastases, inflammatory processes
• Takayasu's arteritis

Workup and Diagnosis

• History and physical exam with focus on abdominal exam (may have palpable thrill), cardiac exam, four extremity pulses, and blood pressure
• Ultrasound is often the initial test and is diagnostic for AAA, liver metastases, and liver and spleen sizes
• Abdominal CT will demonstrate abdominal pathology and is useful to better delineate anatomy
• Arterial Doppler ultrasound
• Angiography is diagnostic for stenosis
• Measuring renal vein renin levels following a captopril challenge is diagnostic for renal artery stenosis
• Radionuclide nephrograms or IV urography will demonstrate differences in perfusion of kidneys with stenotic artery
• Echocardiogram may be indicated to evaluate for valvular dysfunction
• Laboratory studies may include a lipid panel to evaluate for arteriosclerosis; CBC and ESR if inflammatory processes are suspected; liver function tests to evaluate for liver dysfunction; and electrolytes and renal function tests if renal artery stenosis is suspected

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Carotid Bruits: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Internal carotid artery stenosis
• External carotid artery stenosis
• Normal (nonstenotic), yet tortuous, carotid arteries
• Heart murmur with radiation to the neck (e.g., aortic stenosis)
• Excessive compression of the stethoscope over the neck vessels, resulting in deformity of vessel wall and turbulence
• Hyperthyroidism
  –Results in hyperdynamic circulation, tachycardia, and hypertension
• Takayasu's arteritis
  –Decreased pulses and bruits may occur over the abdominal aorta, carotid arteries, brachial arteries, and subclavian arteries
• Fisher's contralateral systolic bruit
  –Heard over the carotid bifurcation, eyeball, and/or skull on the “normal side” due to increased flow, as the “silent” side is completely occluded

Workup and Diagnosis

• Complete history and physical exam, with special attention to cardiac risk factors, TIA symptoms, cardiovascular exam, and neurologic exam
  –Bruit pitch increases as stenosis worsens, but may become silent when full occlusion occurs
  –Amaurosis fugax: Described as a “shade coming down over the eye” contralateral to the stenosis
• Laboratory evaluation includes lipid panel, CBC, glucose, electrolytes, homocysteine level (an independent risk factor for stroke), vitamin B₁₂ and folate levels, TSH, and ESR
• Carotid duplex ultrasound will evaluate the degree of stenosis
• MRA, CTA, or arteriography is indicated to better evaluate symptomatic stenosis that may require surgery

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Source: In a Page: Signs and Symptoms, 2004

Abdominal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Constipation/inability to pass stool
  –Most commonly due to dehydration and/or low dietary fiber intake
  –Hirschsprung's disease (congenital aganglionic megacolon)
  –Medications: Narcotics, opiates, or anticholinergic medications
  –Ogilvie's syndrome (colonic pseudo-obstruction)

• Ascites
  –May be due to malignancy, nephrotic syndrome, liver disease, or congestive heart failure

Large or small bowel obstruction

Soft tissue mass
–Tumor (e.g., ovarian, uterine, bowel, liver)
–Uterine fibroids
–Lipoma: Soft, fleshy, mobile, and contained in the subcutaneous tissue of the abdominal wall
–Hernia: Bowel sounds may be audible over the mass; incarceration causes pain; strangulation leads to bowel death
–Pyloric stenosis: Seen primarily in infants; palpable pyloric olive-shaped mass
–Pregnancy
–Massive lymphadenopathy (e.g., lymphoma)
–Organomegaly (e.g., hepatomegaly, splenomegaly)
–Infection: Intra-abdominal or tubo-ovarian abscess
–Abdominal aortic aneurysm: Associated with pulsatile mass and hypotension

• Cyst
  –Mesenteric cysts: Fluid collections in the mesentery; typically benign
  –Hydatid cyst: Caused by larval form of Echinococcus granulosus; typically found in the liver in patients with history of travel to tropical areas
  –Dermoid cyst: May be massive due to delayed presentation
• Palpable gallbladder (Courvoisier's sign): Associated with common bile duct obstruction and a distended gallbladder

Workup and Diagnosis

• History and physical examination
  –Note associated symptoms (especially fever, changes in bowel habits, weight change, urinary symptoms, and rectal bleeding)
  –Abdominal and pelvic examinations to localize areas of tenderness
• Initial laboratory studies may include CBC, electrolytes, BUN/creatinine, liver function tests, urinalysis, and β-hCG
• Tumor markers (if malignancy is a concern), blood cultures (if infection is suspected), and toxicology screen may be indicated
• Plain KUB X-rays may reveal constipation, obstruction, or free intraperitoneal air
• Abdominal CT scan with IV and oral contrast will evaluate for abscess, bowel pathology, and hepatosplenomegaly
• Barium enema may reveal abnormal bowel in cases of malignancy
• Colonoscopy is useful for diagnosis of bowel pathology
• Laparoscopy allows direct visualization of the intra-abdominal cavity
• Paracentesis with fluid evaluation

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Source: In a Page: Signs and Symptoms, 2004

Abdominal Guarding: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Appendicitis
• Pancreatitis
• Diverticulitis
• Abdominal wall strain/injury
• Pelvic inflammatory disease
• Ectopic pregnancy
• Bowel obstruction
• Ileus
• Pneumonia
• Dyspepsia
• Nephrolithiasis
• Peptic ulcer disease
• Abdominal aortic aneurysm
• Anxiety
• Malingering
• Spontaneous bacterial peritonitis (SBP)
• Mesenteric ischemia
• GERD
• Ovarian cyst
• Hepatic or splenic contusion/laceration
• Pneumoperitoneum secondary to trauma
• Urinary tract infection/pyelonephritis
• Zoster
  –Skin lesions may not be visible until another day or two
• Insect toxins (e.g., black widow spider)
• Abscess (e.g., iliopsoas)
• Incarcerated hernia
• Abdominal migraine
• Intussusception
• Volvulus

Workup and Diagnosis

• History and physical examination
• Initial laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, liver function tests, amylase/lipase, β-hCG, urinalysis, and urine culture
• CT scan is often indicated to diagnose appendicitis, diverticulitis, aneurysm, organ contusion or lacerations, and bowel obstruction
• Abdominal, pelvic, and/or transvaginal ultrasound may be diagnostic for appendicitis, aneurysm, peritonitis, ectopic pregnancy, ovarian cysts, and fluid/blood secondary to trauma
• Plain KUB X-rays may reveal bowel gas pattern and nephrolithiasis
• Paracentesis is diagnostic for spontaneous bacterial peritonitis and may provide symptomatic relief
• Empiric trial of medications may be useful for diagnosis and treatment of GERD/dyspepsia (H2 blocker or proton pump inhibitor), zoster (acyclovir), anxiety (lorazepam), and abdominal wall strain (NSAIDs)
• Cervical cultures to diagnose pelvic inflammatory disease
• Helicobacter pylori testing and upper GI endoscopy may be indicated for suspected cases of peptic ulcer disease

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Source: In a Page: Signs and Symptoms, 2004

Abdominal Masses: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Wilms tumor
  –More common in younger children
• Neuroblastoma
  –More common in younger children
• Leukemia/lymphoma
  –Involvement of retroperitoneal nodes, liver, or spleen
• Hepatic tumors
  –Hepatoblastoma, hepatocellular carcinoma, angiosarcoma, rhabdomyosarcoma of the liver, metastatic disease
• Germ cell tumors
  –Ovarian, teratoma
• Soft tissue sarcoma
  –Rhabdomyosarcoma
• Rare malignancies in children
  –Carcinoid tumors, adrenocortical carcinoma, pancreatoblastoma, malignant rhabdoid tumor
• Cystic masses
  –Ovary, renal, mesenteric
• Benign tumors
  –Adenomas (especially of liver), hamartomas, pheochromocytoma
• Vascular lesions (e.g., hemangioma)
• Renal etiologies
  –Distended, nonemptying bladder, bladder outlet obstruction
  –Congenital mesoblastic nephroma
  –Severe hydronephrosis
• Gynecologic
  –Ovarian torsion, endometriosis, pelvic inflammatory disease
• Gastrointestinal
  –Constipation/stool impaction, intestinal obstruction (e.g., Hirschsprung), GI duplication, incarcerated hernia
• Pancreatic pseudocyst
• Infectious
  –Abscess, hepatitis, virus (EBV, CMV) causing splenomegaly or hepatomegaly
• Structures normally palpable in small children are liver edge, spleen tip (especially with viral illness), aorta, sigmoid colon, and spine

Workup and Diagnosis

• History
  –Mass duration, growth rate, pain; fever, weight loss, bone pain, night sweats
  –Anorexia, vomiting, constipation or diarrhea, early satiety, jaundice; prematurity, umbilical catheterization; opsoclonus, myoclonus (neuroblastoma)
  –Vaginal bleeding/amenorrhea, sexual activity, previous pregnancies/fertility, history of STDs; urinary dysfunction, congenital urinary tract anomalies
  –Signs of catecholamine excess (sleeplessness, jitteriness, flushing, hypertension)

• Family history: Wilms tumor, neurofibromatosis, hepatic tumors, Beckwith-Wiedemann
• Physical exam: Vital signs, toxicity, pallor, puffiness; location, size, tenderness, consistency of mass; hemihypertrophy (with Wilms), lymph nodes; wheezing, rales, SVC syndrome; presence of ascites, visible venous dilation; testicular exam, rectal; pelvic examination in teenagers; petechiae, purpura/ecchymoses, café au lait spots
• Labs: CBC with differential; electrolytes, BUN, Cr, LFT albumin, urinalysis; LDH, uric acid, PT/PTT/INR, ferritin, viral titers (EBV, CMV, hepatitis), tumor markers, stool guaiac
• Studies: KUB/upright film, chest X-ray; CT of chest/abdomen/pelvis; abdominal ultrasound; bone marrow aspirate/biopsy

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Source: In A Page: Pediatric Signs and Symptoms, 2007

ABDOMINAL MASS, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

What can be done to work up a diffuse abdominal swelling? It is important to catheterize the bladder if there is any question that this may be the cause. A flat plate of the abdomen and lateral decubiti and upright films will help in diagnosing intestinal obstruction, a ruptured viscus, or peritoneal fluid. A pregnancy test must be done in women of childbearing age. If pregnancy or ovarian cysts can be definitively excluded by ultrasonography, then a computed tomography (CT) scan or diagnostic peritoneal tap may be helpful in the diagnosis.

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Source: Differential Diagnosis in Primary Care, 2007

Abdominal mass: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menstrual period was.

A complete physical examination should be performed. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Also, percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.

Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can’t, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes.)

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Bruits: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen's sign). Either of these signs — or severe, tearing pain in the abdomen, flank, or lower back — may signal life-threatening dissection of an aortic aneurysm. Also, check peripheral pulses, comparing intensity in the upper versus lower extremities.

If you suspect dissection, monitor the patient's vital signs constantly, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; a weak, thready pulse; tachypnea; an altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.

If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.

If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.

If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation — edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Also, watch for the sudden absence of pulse, pallor, or coolness, which may indicate a threat to the affected limb.

If you detect a bruit, make sure to check for further vascular damage and perform a thorough cardiac assessment.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s condition allows further assessment, take a brief history. Find out when the abdominal rigidity began. Is it associated with abdominal pain? If so, did the pain begin at the same time? Determine whether the abdominal rigidity is localized or generalized. Is it always present? Has its site changed or remained constant? Next, ask about aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.

Explore other signs and symptoms. Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Also, check for a visibly distended bowel loop. Next, auscultate bowel sounds. Perform light palpation to locate the rigidity and determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal aneurysm: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Because abdominal aneurysms seldom produce symptoms, they’re commonly detected accidentally as the result of an X-ray or a routine physical examination.

Confirming diagnosis  

Several tests can confirm a suspected abdominal aneurysm. Serial ultrasound (sonography) can accurately determine the aneurysm’s size, shape, and location. Anteroposterior and lateral X-rays of the abdomen can detect aortic calcification, which outlines the mass, at least 75% of the time. Aortography shows the condition of vessels proximal and distal to the aneurysm and the aneurysm’s extent but may underestimate aneurysm diameter because it visualizes only the flow channel and not the surrounding clot. Computed tomography scan is used to diagnose and size the aneurysm. Magnetic resonance imaging can be used as an alternative to aortography.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Femoral and popliteal aneurysms: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis is usually confirmed by bilateral palpation that reveals a pulsating mass above or below the inguinal ligament in femoral aneurysm. When thrombosis has occurred, palpation detects a firm, nonpulsating mass. Arteriography or ultrasound may be indicated in doubtful situations. Arteriography may also detect associated aneurysms, especially those in the abdominal aorta and the iliac arteries. Ultrasound may be helpful in determining the size of the popliteal or femoral artery.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Abdominal mass: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, take a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in its size or location.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the 1st day of her last menstrual period was.

Perform a complete physical examination. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Also, percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.

Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can’t, the mass is within the abdominal cavity. (See Abdominal masses: Locations and causes, page 10.)  

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Bruits: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen’s sign). Either of these signs—or severe, tearing pain in the abdomen, flank, or lower back—may signal life-threatening dissection of an aortic aneurysm. Also check peripheral pulses, comparing intensity in the upper and lower extremities.

If you suspect dissection, monitor the patient’s vital signs continuously, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; weak, thready pulse; tachypnea; altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.

If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.

If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.

If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation—edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Pallor, coolness, or the sudden absence of a pulse may indicate a threat to the affected limb.

If you detect a bruit, be sure to check for further vascular damage and perform a thorough cardiac assessment.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s condition allows further assessment, take a brief history. Find out when the abdominal rigidity began. Is it associated with abdominal pain? If so, did the pain begin at the same time? Determine whether the rigidity is localized or generalized. Is it always present? Has its location changed or remained constant? Next, ask about aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.

Then explore other signs and symptoms. Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Also check for a visibly distended bowel loop. Next, auscultate bowel sounds. Perform light palpation to locate the rigidity and to determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

Diagnostic Approach

Consider the structures in the region of the mass for clues to its origin and the presence of tenderness as an indicator of inflammation/infection. It is possible to miss initially even a relatively large mass unless a systematic four-quadrant examination is performed.

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Source: Field Guide to Bedside Diagnosis, 2007

Carotid Bruit: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Carotid artery stenosis

❑ Carotid artery ruptured plaque

❑ Transmitted valvular murmur

❑ Carotid tortuosity

❑ Carotid compression

❑ Jugular venous hum

❑ Thyrotoxicosis

Diagnostic Approach

Carotid bruits are imperfect markers of increased stroke risk because stroke is usually not due to progressive carotid stenosis, but rather to ruptured plaque, cardiac emboli from atrial fibrillation, emboli from aortic sources, or watershed ischemia due to decreased flow. A bruit is, however, an important marker of generalized atherosclerosis. The annual incidence of stroke in the territory of a carotid bruit is 1.7%/year and increases to 5.5%/year as stenosis exceeds 75%. The risk of death (usually cardiac) in a patient with a carotid bruit is 4%/yr. Bruits are clinically significant when associated with transient ipsilateral anterior circulation symptoms such as amaurosis fugax (transient monocular blindness), contralateral homonymous hemianopsia, hemiparesis, and hemisensory defect. Left hemispheric lesions are associated with aphasia, and right with visuospatial neglect and constructional apraxia.

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Source: Field Guide to Bedside Diagnosis, 2007

Aneurysm, abdominal: Diagnosis
(Handbook of Diseases)

Because an abdominal aneurysm rarely produces symptoms, it’s usually detected accidentally as the result of an X-ray or a routine physical examination. Several tests can confirm suspected abdominal aneurysm:

Serial ultrasonography allows accurate determination of aneurysm size, shape, and location.

Anteroposterior and lateral X-rays of the abdomen can detect aortic calcification, which outlines the mass, at least 75% of the time.

Aortography shows the condition of vessels proximal and distal to the aneu-rysm and the extent of the aneurysm but may underestimate the aneurysm’s diameter because it visualizes only the flow channel and not the surrounding clot.

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Source: Handbook of Diseases, 2003

Aneurysms, femoral and popliteal: Diagnosis
(Handbook of Diseases)

With femoral aneurysm, the diagnosis is usually confirmed by bilateral palpation that reveals a pulsating mass above or below the inguinal ligament. When thrombosis has occurred, palpation detects a firm, nonpulsating mass.

Arteriography or ultrasonography may be indicated in doubtful situations. Arteriography may also detect associated aneurysms, especially those in the abdominal aorta and the iliac arteries. Ultrasonography may be helpful in determining the size of the femoral or popliteal aneurysm.

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Source: Handbook of Diseases, 2003

aneurysm,ventricular: Diagnosis
(Handbook of Diseases)

Persistent ventricular arrhythmias, onset of heart failure, or systemic embolization in a patient with left-sided heart failure and a history of MI strongly suggests a ventricular aneurysm. Indicative tests include the following:

Left ventriculography reveals left ventricular enlargement with an area of akinesia or dyskinesia (during cineangiography) and diminished cardiac function.

Electrocardiography may show persistent ST-T wave elevations after an MI.

Chest X-ray may demonstrate an abnormal bulge distorting the heart’s contour if the aneurysm is large; the X-ray may be normal if the aneurysm is small.

Noninvasive nuclear cardiology scan may indicate the site of infarction and suggest the area of aneurysm.

Echocardiography shows abnormal motion in the left ventricular wall.

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Source: Handbook of Diseases, 2003

Aneurysm, thoracic aortic: Diagnosis
(Handbook of Diseases)

Patient history, signs and symptoms, and appropriate tests provide diagnostic information. In an asymptomatic patient, diagnosis may occur accidentally when chest X-rays show widening of the mediastinum. The following other tests help confirm an aneurysm:

Aortography, the definitive test, shows the lumen of the aneurysm, its size and location, and the false lumen in a dissecting aneurysm.

Electrocardiography (ECG) helps distinguish a thoracic aneurysm from a myocardial infarction.

Echocardiography may help identify a dissecting aneurysm of the aortic root.

Hemoglobin level may be normal or low because of blood loss from a leaking aneurysm.

Computed tomography scan can confirm and locate the aneurysm and may be used to monitor its progression.

Magnetic resonance imaging may aid diagnosis.

Transesophageal echocardiography is used to measure the aneurysm in both the ascending and the descending aorta.

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Source: Handbook of Diseases, 2003

Abdominal mass: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menses was.

CULTURAL CUE:When taking a health history, consider your patient’s ethnic background. For example, Japanese patients are at higher risk for gastric cancer than non-Japanese patients and cirrhosis tends to be more common in Native American patients than in patients of other ethnic backgrounds.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Bruits: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Obtain a medical history including past injuries, illnesses, surgeries, and family medical history. Ask about diet and alcohol intake. Take a drug history, including past and present prescriptions, over-the-counter drugs, and herbal remedies. Also obtain a social history.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal Masses: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Right Upper Quadrant

Liver

Hepatomegaly

Palpablein right upper quadrant of abdomen. Palpable in midline or leftupper quadrant with abdominal heterotaxia (commonly associated withcomplex congenital heart disease).

See Chap.30, Hepatomegaly.

Hepatic Cyst

May presentas asymptomatic hepatic mass.

Abdominal U/S is diagnostic.

Primary Hepatic Neoplasms

AbdominalU/S distinguishes between cystic or solid masses. CT defineslocation and extent of tumor.

Histologic diagnosis is definitive.

Benign

Hemangioma,mesenchymal hamartoma, and focal nodular hyperplasia usually presentin infancy as asymptomatic hepatic masses.

Hemangioendothelioma usually presentsbefore 6 mos of age as hepatic mass or with massive hepatomegalyand cardiac failure secondary to multiple arteriovenous communicationswithin tumor. Diagnosis may be confirmed by selective angiography.

Hepatic adenoma is rare tumor thatusually presents after puberty.

Hepatic teratoma can be benign or malignantand is rare in pediatric age group.

Malignant

Hepatoblastomais most common hepatic malignant tumor in pediatric population andusually occurs in children <2 yrs of age.

Hepatomegalyis most frequent physical finding. Discrete mass is usually notpalpable.

Abdominal U/S shows single,solid liver mass.

Serum alpha-fetoprotein (AFP) levelsare increased in most cases.

Hepatocellular carcinoma usually occursin children >3 yrs of age, with peak incidence in adolescence.

Clinical manifestationsinclude right upper quadrant mass, abdominal pain, anorexia, andweight loss.

Abdominal U/S shows solidhepatic mass, and AFP levels may be increased.

Often a complication of chronic hepatitisB infection.

Gallbladder

Cholecystitis

Occurrenceis usually related to presence of gallstones.

Right upper quadrant pain, vomiting,and fever are usual findings. Enlarged tender gallbladder may bepalpable.

Abdominal U/S usually revealsstones and thickened gallbladder wall.

Hydrops of Gallbladder

Hydropsrefers to distension of gallbladder without inflammation.

Causes include Kawasaki disease, nephroticsyndrome, staphylococcal or streptococcal infection, and, in neonates,septicemia and total parenteral nutrition.

Gallbladder is enlarged and often palpable.

Abdominal U/S confirms thatmass is gallbladder.

Biliary Tree

Choledochal Cyst

Infantsmay present with jaundice, acholic stools, and hepatomegaly. Childrenmay present with jaundice, abdominal mass, or abdominal pain.

4 types are fusiform dilation of commonbile duct (most common), diverticulum of common duct, dilatationof distal portion of common duct, and dilatation of extra- and intrahepaticbile ducts.

Diagnosis usually confirmed by abdominalU/S.

Intestine

Pyloric Stenosis

Hypertrophicpyloric stenosis produces an olive-sized mass in right upper quadrant ofabdomen, but it is not always palpable.

Usually occurs in infants 1–8wks of age.

Most consistent finding is persistentnonbilious vomiting during or immediately after feeding.

Physical exam can be diagnostic ifmass is palpable.

Diagnosis can be confirmed by abdominalU/S or upper GI radiographic series.

Duodenal Hematoma

Usuallycaused by blunt abdominal trauma.

Common findings are abdominal painand bilious vomiting. Mass may be palpable in right upper quadrantor epigastric region.

Abdominal U/S or upper GIradiographic series is diagnostic.

Duplication

Can occuranywhere in GI tract but most commonly involves ileum and colon.Compressible mass may be palpable anywhere in abdomen. Abdominalpain, vomiting, and GI bleeding are common findings.

Abdominal U/S and CT are usuallydiagnostic. Technetium 99m–pertechnetate scan can detectectopic gastric mucosa.

Diagnosis is confirmed at surgery.

Left Upper Quadrant

Spleen

Splenomegaly

Enlargedspleen is normally palpable in left upper quadrant of abdomen, unlessabdominal heterotaxia exists, in which case it is palpable in midlineor right upper quadrant.

Abdominal heterotaxia is usually associatedwith congenital complex heart disease.

See Chap.62, Splenomegaly.

Splenic Cyst

May be congenitalor occur secondary to trauma.

Smooth mass that displaces stomachmedially is usually palpable.

Abdominal U/S is diagnostic.

Neoplasm

See Chap.62, Splenomegaly.

Epigastric

Stomach

Bezoar

May be palpableas epigastric mass. Vomiting and abdominal distension are common findings.

Abdominal U/S or upper GIseries is diagnostic.

See Chap.55, Regurgitation and Vomiting.

Duplication

Frequentmanifestations are vomiting and epigastric mass. Bleeding from duplication alsomay produce hematochezia.

Abdominal U/S is usually diagnostic.

Pancreas

Pancreatic Cyst

May presentas asymptomatic abdominal mass or with abdominal distension, vomiting,and jaundice.

Abdominal U/S or CT is usuallydiagnostic.

Pancreatic Pseudocyst

Accountsfor majority of cystic lesions of pancreas and is usually locatedin lesser sac.

Its wall is composed of granulationtissue and not epithelium.

Most common causes are abdominal traumaand pancreatitis (idiopathic).

Abdominal pain, vomiting, anorexia,weight loss, and epigastric mass are frequent findings.

Combination of abdominal U/Sand CT is usually diagnostic.

Neoplasm

Usuallycarcinomas or rare endocrine tumors.

Abdominal U/S and CT locateand define extent of mass. Histologic diagnosis is definitive.

Right/Left Mid-Abdomen

Kidney

In neonates, >50% of abdominalmasses involve urinary tract. Most are unilateral.

Hydronephrosis

Definedas distension of kidney pelvis and calyces produced by obstructionanywhere in genitourinary tract.

Most common abdominal mass in neonate;can be unilateral or bilateral.

Specific causes include ureteropelvicjunction, ureteral, or ureterovesical obstruction; ureterocele;posterior urethral valves; and prune belly syndrome. Besides largeabdominal or flank mass, abdominal or flank pain, hematuria, vomiting,poor weight gain, recurrent fever, and urinary tract infection mayoccur.

Abdominal U/S is usually diagnostic.

Useful tests to determine site of obstructioninclude excretory urography, voiding cystourethrography, cystoscopy,and retrograde pyelography.

Multicystic Dysplastic Kidney

Second mostcommon abdominal mass found in neonate.

Usually unilateral and asymptomatic.

Consists of cysts of various sizesand is almost always nonfunctional.

Although abdominal U/S isdiagnostic, renal scintigraphy is useful in demonstrating renal function.

Renal Vein Thrombosis

Occurs mostcommonly in neonatal period and can be unilateral or bilateral.

History of perinatal asphyxia or hypovolemiausually exists. Maternal diabetes mellitus is frequent association.

Common findings include flank mass,hematuria, proteinuria, azotemia, thrombocytopenia, and transienthypertension.

Abdominal U/S or CT is usuallydiagnostic.

Renal scintigraphy demonstrates kidneyfunction, which may be diminished in 1 or both kidneys.

Congenital Mesoblastic Nephroma

Usuallypresents as asymptomatic abdominal or flank mass.

Renal U/S locates solid tumor.

Histologic diagnosis is confirmatory.

Wilms Tumor

Definedas embryonal renal tumor that usually presents as unilateral, smooth,mobile flank mass before 3 yrs of age. May be bilateral. Abdominalpain, hematuria, fever, hypertension, aniridia, and hemihypertrophymay occur.

Combination of abdominal U/Sand CT define location and extent of tumor, including any presencein inferior vena cava. Histologic diagnosis is definitive.

Renal Cyst, Ectopic Kidney, and Horseshoe Kidney

May presentas abdominal or flank masses.

Abdominal U/S confirms diagnosis.

Renal or Perinephric Abscess

High spikingfever and abdominal or flank mass suggest renal or perinephric abscess.

Abdominal U/S and CT are usuallydiagnostic. Percutaneous needle drainage or surgery confirms diagnosis.

Polycystic Kidney Disease

Autosomal-recessivepolycystic kidney disease can present in neonatal period with bilateralflank masses, which are firm, large, irregular kidneys. Other findingsinclude hematuria, proteinuria, azotemia, and hypertension.

Abdominal U/S reveals largeechogenic kidneys.

Autosomal-dominant polycystic kidneydisease, which usually occurs in adults, also can present with unilateralor bilateral enlarged kidneys.

Beckwith-Wiedemann Syndrome

Autosomal-dominantdisorder that can occur sporadically.

Kidneys may be enlarged. Other manifestationsinclude generalized overgrowth, macroglossia, omphalocele, and hepatomegaly.

Hypoglycemia is most urgent featurein newborn.

Gene locus has been mapped to chromosome11p15.5.

Adrenal

Neonatal Adrenal Hematoma

May occurafter traumatic delivery, asphyxia, or septicemia.

With massive bleeding, infant may presentin shock. With less severe bleeding, abdominal mass may be palpable,usually on right side and accompanied by anemia and jaundice. Massusually decreases in size and disappears over several weeks.

Abdominal U/S is usually diagnostic.

Neuroblastoma

May arisefrom adrenal medulla or any site along sympathetic chain.

Mean age of presentation is about 2yrs of age.

Hard, fixed abdominal mass is commonfinding. Abdominal pain, weight loss, fever, bone pain, eyelid ecchymoses,and bluish subcutaneous nodules also may occur. In some cases opsoclonusand cerebellar ataxia have been noted.

Metastases may involve regional lymphnodes, bone marrow, bone, liver, and skin.

Abdominal radiographs may show massand typical punctate calcifications. Abdominal U/S alsocan locate mass, while CT or MRI can define its extent.

Increase in 24-hr urine excretion ofcatecholamines (norepinephrine, dopamine, normetanephrine, homovanillicacid, vanillylmandelic acid) is usually found.

Chest radiograph, skeletal bone survey,nuclear scintigraphy, and bone marrow aspirate should be performedsearching for metastatic disease.

Diagnosis confirmed by histologic examof tissue.

Periumbilical

Intestine

Mesenteric Cyst

Usuallyarises in mesentery of jejunum or ileum and enlarges slowly.

Abdominal mass is often palpable.

Abdominal U/S is usually diagnostic.

Volvulus

Infantspresent with symptoms and signs of intestinal obstruction such aspersistent vomiting and abdominal distension. Occasionally abdominalmass may be palpable.

See Chap.22, Gastrointestinal Bleeding and Chap. 55, Regurgitation and Vomiting.

Neoplasm

Tumors ofGI tract in newborn and young infant are extremely rare.

In their series, Longino and Martin(1958) described just 1 case of leiomyosarcoma of colon.

In children and adolescents, most commontumor of GI tract is non-Hodgkin lymphoma.

Right Lower Quadrant

Intestine

Abscess

May producemass in right lower quadrant.

Usual findings are high, spiking, persistentfever and localized abdominal pain and tenderness. Tender mass maybe palpable on rectal exam.

Many are due to ruptured appendix.

CT is usually diagnostic. Diagnosisof appendiceal abscess is confirmed at interval appendectomy, whichusually occurs about 6 wks after drainage of abscess.

Intussusception

Usuallyoccurs at 6–24 mos of age.

Other findings that suggest diagnosisare intermittent, colicky abdominal pain; vomiting; and currantjelly, blood-tinged, or guaiac-positive stools.

If suspected clinically, perform aircontrast enema, which may be therapeutic as well as diagnostic.

Lymphoma

May presentas abdominal mass ± intestinal obstruction.

Localized or generalized lymphadenopathymay provide clue to diagnosis, and lymph node biopsy may be diagnostic.

Abdominal U/S and CT usuallylocate and define extent of mass.

Histologic diagnosis is definitive.

Ovary

Cyst

May be asymptomaticand only found on routine exam. May also present with acute abdominalpain secondary to torsion or hemorrhage or with chronic abdominalpain.

Most occurrences in adolescence aresimple follicular cysts that persist because of failure of maturingfollicle to ovulate and involute. Resolution usually occurs in 1–2mos.

Abdominal U/S is diagnostic.

Torsion

Producesacute abdominal pain, which may be accompanied by nausea, vomiting,and fever.

Abdominal U/S is often diagnostic.Diagnosis confirmed at surgery.

Neoplasm

Rare inpediatric population.

Teratoma is most common benign tumor,whereas malignant tumors include dysgerminoma, endodermal sinustumor, immature teratoma, mixed germ cell tumor, embryonal carcinoma,and choriocarcinoma.

Palpable abdominal mass and varyingdegrees of acute or chronic abdominal pain may occur.

Less common findings are constipation,urinary incontinence, precocious puberty, vaginal bleeding, andamenorrhea.

Abdominal U/S localizes mass,determines whether it is cystic or solid, and detects any calcifications.

Tumor markers (e.g., AFP, hCG, lacticdehydrogenase, carcinoembryonic antigen) may be useful for selectedtumors.

Abdominal CT and MRI help define siteand extent of tumor and if there are any local metastases. Histologicdiagnosis is definitive.

Left Lower Quadrant

Intestine

Constipation

Most commoncause of abdominal mass or masses in infancy and childhood.

History usually exists of strainingwhile attempting to have bowel movement. Stools are hard and difficultto pass. Multiple, mobile stool masses usually occur in left lowerquadrant and disappear with defecation.

Sometimes rectal exam reveals a fecalimpaction.

See Chap.9, Constipation.

Hypogastrium

Bladder

Distension/Obstruction

Can usuallybe recognized on abdominal exam, or if necessary, by abdominal U/S.

Common causes are urethritis, anticholinergicdrugs, and lower urinary tract obstruction from lesions such asposterior urethral valves (males).

Uterus

Pregnancy

Intrauterinepregnancy presents as midline lower abdominal or pelvic mass insexually active female.

Symptoms and signs of early pregnancyinclude missed menstrual period, nausea, vomiting, lack of usualenergy, and enlarged tender breasts.

After 12 wks' gestation, uterinefundus may be palpable above symphysis pubis.

After 20 wks' gestation, uteruscan reach level of umbilicus.

Positive urine hCG pregnancy test confirmsdiagnosis.

Hydrometrocolpos

Definedas fluid-filled dilated vagina and uterus that may be due to imperforatehymen or vaginal atresia.

Imperforate hymen can be noted on genitalexam. With vaginal atresia, dimpled area occurs where vaginal openingshould be.

Delay of diagnosis until adolescenceresults in failure of menstrual flow and enlarged palpable uterus.

Abdominal or pelvic U/S isuseful in diagnosis.

Diagnostic Approach

Age of child,location and characteristics of mass, and associated clinical findingsare important factors in diagnosis.

Liver masses are in right upper quadrant,splenic masses in left upper quadrant, and kidney masses in flanks;masses involving intestine and ovaries are likely to be palpablein lower quadrants.

Any solid mass should be consideredmalignant until proved otherwise.

If diagnosis is uncertain after historyand physical exam, abdominal radiographs should be performed.

Most useful single test is abdominalU/S, which usually locates involved organ of origin and whethermass is solid or cystic, renal or extrarenal.

CT and MRI play important role by demonstratinganatomic features of mass as well as local and metastatic extentof malignant lesions.

Chest radiograph may be useful, especiallywith suspected neoplastic lesions.

Renal Masses

Responsiblefor >50% of palpable abdominal masses in neonates.

If mass is intrarenal, cystic, andsolitary, it is usually benign renal cyst. If it is cystic and multiloculated,renal multicystic dysplasia is usual diagnosis.

In infants <1 yr, solid renalmasses are either congenital mesoblastic nephroma or Wilms tumor.These 2 tumors are indistinguishable by imaging exam.

In children >1 yr, nearlyall solid intrarenal masses are Wilms tumors.

Gastrointestinal Masses

Plain abdominalradiography and abdominal U/S are most important initialstudies.

Other studies depend on suspected diagnosis:air-contrast enema (intussusception), CT (intestinal duplication,abscess, neoplasm), and upper GI series (volvulus).

Liver Masses

Cystic lesionsare usually benign cysts, whereas solid intrahepatic lesions usuallysignify tumor. In latter case, CT and/or MRI help definelocation and extent of the mass.

Histologic diagnosis is confirmatory.

Splenic Masses

May be diagnosedby abdominal U/S.

Malignant disease usually is infiltrativein nature (leukemia) and causes splenomegaly rather than discretesplenic mass. Involvement of the spleen by lymphoma may be infiltrativeor with discrete tumor foci.

Biliary Tract Masses

Most arecystic and benign (choledochal cyst, hydrops of gallbladder) inchildren.

Can usually be diagnosed by abdominalU/S.

Adrenal Masses

Abdominal U/S can distinguish adrenalhematoma from neuroblastoma. Imaging cannot distinguish betweenneuroblastoma, ganglioneuroma, or ganglioneuroblastoma, and histologicdiagnosis is mandatory.

Genital Tract Masses

Usuallyovarian cysts in infant girls.

May be readily diagnosed by abdominalU/S.

Most common pelvic tumors in girlsare ovarian tumors. Further imaging is needed with CT or MRI.

With pelvic mass in postmenstrual female,pregnancy test and U/S should be performed.

If mass appears to be small functionalfollicular cyst, individual should be observed for 2–3mos to see whether it regresses.

If it is >5 cm in diameterat time of diagnosis or suspicion of malignancy exists, laparoscopy orlaparotomy should be performed to make definitive histologic diagnosis.

Pancreatic Masses

Most arepseudocysts and require no further imaging other than abdominalU/S.

Rarely, solid pancreatic tumors occurand are either carcinomas or endocrine tumors.

>>

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Abdominal mass: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's abdominal mass doesn't suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient's medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and the first day of her last menses.

A complete physical examination should be performed. Inspect the abdomen for asymmetry, scarring, discoloration, or other skin abnormalities. Also observe for pulsations. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient's position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.

Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can't, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes, page 8.)

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Bruits: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen's sign). Either of these signs—or severe, tearing pain in the abdomen, flank, or lower back—may signal life-threatening dissection of an aortic aneurysm. Check peripheral pulses, comparing intensity in the upper versus lower extremities.

If you suspect dissection, monitor the patient's vital signs constantly, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; a weak, thready pulse; tachypnea; an altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.

If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.

If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.

If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation, such as edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Watch for the sudden absence of pulse, pallor, or coolness, which may indicate a threat to the affected limb.

If you detect a bruit, make sure to check for further vascular damage and perform a thorough cardiac assessment.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's condition allows further assessment, take a brief history. Find out when the abdominal rigidity began. Is it associated with abdominal pain? If so, did the pain begin at the same time? Determine whether the abdominal rigidity is localized or generalized. Is it always present? Has its site changed or remained constant? Next, ask about aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.

Explore other signs and symptoms. Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Check for a visibly distended bowel loop or pulsations. Next, auscultate bowel sounds. Perform light palpation to locate the rigidity and determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal Mass, Generalized: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

What can be done to work up a diffuse abdominal swelling? It is important to catheterize the bladder if there is any question that this may be the cause. A flat plate of the abdomen and lateral decubiti and upright films will help in diagnosing intestinal obstruction, a ruptured viscus, or peritoneal fluid. A pregnancy test must be done in women of childbearing age. If pregnancy or ovarian cysts can be definitively excluded by ultrasonography, then a computed tomography (CT) scan or diagnostic peritoneal tap may be helpful in the diagnosis.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Abdominal aortic aneurysm

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