Documentation of a Palpated Abdominal Mass
Document the mass systematically by recording its size in centimeters, precise anatomical location relative to landmarks, margin characteristics (well-defined versus irregular), mobility, consistency, and any attachment to skin or deep fascia. 1
Essential Physical Examination Components
When charting a palpated abdominal mass, your documentation must include specific tactile findings that guide subsequent imaging and management decisions:
Size and Location
- Measure and record the mass dimensions in centimeters using calipers or estimation during palpation 1
- Document the anatomical location using standard abdominal quadrant terminology or distance from identifiable landmarks (e.g., "8 cm mass located 3 cm below the umbilicus in the left lower quadrant") 2
- For gastric or intestinal masses, specify the location using standardized notation when applicable 2
Margin Characteristics
- Describe whether margins are well-defined/circumscribed versus irregular or ill-defined, as this distinction significantly impacts the differential diagnosis and urgency of workup 1
- Well-defined margins suggest benign processes like lipomas, while irregular margins raise concern for malignancy 2
Mobility and Attachment
- Document whether the mass is mobile or fixed to underlying structures 1
- Specify any attachment to skin or deep fascia, as fixation suggests more aggressive pathology 1
- Note if the mass moves with respiration (suggesting intra-abdominal origin) or remains stationary (suggesting abdominal wall origin) 3
Consistency and Texture
- Record the consistency: soft, firm, hard, or fluctuant 1
- Pulsatile quality is critical to document, as it suggests vascular etiology, particularly abdominal aortic aneurysm 2, 4
Critical Clinical Pitfall
Physical examination alone has only 85% accuracy in correctly identifying even common masses like lipomas, and cannot reliably distinguish benign from malignant lesions 2, 1. Therefore, your documentation should explicitly state that imaging evaluation is necessary regardless of your clinical impression 1. A highly suspicious physical examination should prompt tissue sampling even if subsequent imaging appears reassuring 1.
Immediate Next Steps to Document
After documenting the physical findings, your note should include:
- For pulsatile masses: Ultrasound is indicated as first-line imaging with 95% sensitivity and near 100% specificity for abdominal aortic aneurysm 1, 5
- For non-pulsatile masses: Ultrasound remains the appropriate initial imaging modality, with CT with IV contrast reserved for cases where ultrasound is negative but clinical suspicion remains high, or when further characterization of a solid mass is needed 1
- Document any red flags requiring urgent imaging: rapid growth, size >2 cm, irregular margins, or constitutional symptoms 1