Recovery and identification methods for these organisms from food, water or diarrheal specimens are based upon the efficacy of selective media and results of microbiological and biochemical assays. The ability to produce enterotoxin(s) may be determined by cell culture assay and animal bioassays, serological methods, or genetic probes.
(Source: FDA Bad Bug Book)
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Gastroenteritis:
The basic workup includes a CBC, sedimentation rate, urinalysis, urine drug screen, chemistry panel and electrolytes, serum amylase, arterial blood gases, stools for occult blood, chest x-ray, EKG, and flat plate of the abdomen. Acute onset of nausea and vomiting with ataxia requires an immediate CT scan of the brain to rule out a cerebellar hemorrhage. A pregnancy test should be routine in women of child-bearing age. If there is fever, febrile agglutinins and a heterophile antibody titer should be done. If there is an abdominal mass, a gallbladder ultrasound and intravenous pyelogram may need to be done. Isotope scanning with iminodiacetic acid derivatives is extremely useful to detect acute cholecystitis. If there is chronic vomiting and abdominal pain, the diagnosis can often be made with an upper GI series, small bowel series, or barium enema.
When there is persistent vomiting with abdominal pain, an exploratory laparotomy may need to be considered. The presence of an abdominal mass or suspected pancreatic or biliary disease merits consideration of a CT scan. However, before ordering expensive diagnostic tests, a general surgeon or gastroenterologist ought to be consulted. Laparoscopy, gastroscopy, esophagoscopy, duodenoscopy, and colonoscopy all need to be considered in the workup. Gastroparesis and intestinal pseudo-obstruction can be ruled out by radioisotope studies and manometry of the stomach and small intestine. Angiography is useful to diagnose mesenteric artery ischemia.
Anatomic/obstructive
–Pyloric stenosis: Classic description of progressive projectile vomiting; more common among first-born males and typically presents in weeks 4–8 of life; may see hypochloremic, hypokalemic metabolic alkalosis
–Hiatal hernia
–Pyloric atresia
–Gastric volvulus
–Gastric outlet obstruction due to chronic
granulomatous disease, peptic ulceration near
the pyloris, or gastric tumors
–Duodenal web
–Duodenal atresia
–Duodenal stenosis
–Superior mesenteric artery syndrome:
Typically due to weight loss, postsurgical correction of scoliosis, or immobilization with body cast
–Urinary tract obstruction: Ureteropelvic junction obstruction (abdominal pain and vomiting known as Dietl crisis); nephrolithiasis
-
Inflammatory
–Gastroesophageal reflux disease
–Peptic ulcer disease
–Pyelonephritis
–Meningitis
–Encephalitis
–Eosinophilic enteropathy
-
Central nervous system
–Brain tumor
–Trauma
–Lead encephalopathy
–Acute intracranial hemorrhage
–Hydrocephalus
-
Metabolic/endocrine
–Congenital adrenal hyperplasia
–Hypercalcemia
–Wolman disease
–Phenylketonuria
Workup and Diagnosis
-
Differentiating vomiting from projectile vomiting is often difficult when obtaining history
-
History: Age at presentation, frequency and amount of emesis, time after feeding until emesis, bilious or nonbilious, hematemesis, weight loss, fever, diarrhea, abdominal pain, melena, hematochezia, activity level, dysuria, menses, pica, recent trauma
-
Birth history: Meconium in nursery, oligohydramnios, polyhydramnios, newborn screen, birth weight
-
Family history: First born
-
Diet history: Formula intolerance
-
Surgical history: Previous abdominal surgeries
-
Social history: House built before 1965 (lead paint)
-
Physical exam: Weight, height, head cirumference, vital signs, mucous membranes, fontanelle, papilledema, equal breath sounds, abdominal distension, abdominal mass (palpable olive in pyloric stenosis), bowel sounds, skin turgor, capillary refill, reflexes, tone, strength
-
Chemistry panel with focus on chloride, CO2, potassium, calcium; CBC with differential for signs of infection, consider urine analysis and culture
-
Abdominal films for obstruction
-
Ultrasound a sensitive and specific method for pyloric stenosis; findings of elongation of pyloric channel and thickening of pyloric muscle; U/S for pelvic obstruction
-
Upper GI series for malrotation, atresia, superior mesenteric artery
-
CT scan for head or abdominal mass
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
NAUSEA AND VOMITING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is essential in pinpointing the diagnosis of vomiting. For example, vomiting with tinnitus and vertigo suggests Ménière disease, whereas vomiting with hematemesis suggests gastritis, esophageal varices, and gastric ulcers. The laboratory workup should include a flat plate of the abdomen, upper GI series, esophagram, cholecystogram, gastric analysis, serum electrolytes, and amylase and lipase levels. Stools for occult blood, ova, and parasites are usually indicated. Gastroscopy and esophagoscopy are often indicated in the acute case, but an exploratory laparotomy should not be delayed if the patient’s condition is deteriorating and pancreatitis has been excluded.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Abdominal distention:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat. (See Abdominal distention: Common causes and associated findings.)
The patient may also feel unable to bend at his waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.
Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites, page 4.) Also, note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, such as falling off a stepladder.
Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obesity. Inspect the abdomen for signs of inguinal or femoral hernia and for incisions that may point to adhesions. Both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash — a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. However, an abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.
Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally with the patient in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen without shifting dullness, prominent tympany, or palpable bowel or other masses, with generalized rather then localized dullness.
Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient’s abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Bowel sounds, hyperactive:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you've ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient's problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vomiting:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.
Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.
Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.
During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Gastroenteritis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Patient history can aid in the diagnosis of gastroenteritis. Stool culture (by direct rectal swab) or blood culture identifies the causative bacteria or parasites.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Abdominal distention:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heartbeat, and difficulty breathing deeply or breathing when lying flat. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.
Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.
Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, glistening skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or an umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obese individuals. Inspect the abdomen for signs of an inguinal or femoral hernia and for incisions that may point to adhesions; both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for a succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.
Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally when the patient is in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen with generalized rather then localized dullness and without shifting dullness, prominent tympany, or palpable bowel or other masses.
Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference point for subsequent measurements. (See Abdominal distention: Causes and associated findings, pages 6 and 7.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Bowel sounds, hyperactive:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you’ve ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent episodes of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vomiting:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask your patient to describe the onset, duration, and intensity of his vomiting. What started it? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel elimination patterns or the appearance of stools, excessive belching or flatus, and bloating or fullness.
Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant and which contraceptive method she uses.
Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.
During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with a CNS injury, quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Nausea and Vomiting:
History.
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
As is usually the case in clinical practice, most diagnoses will be made by history and confirmed by physical examination and laboratory studies. Key points in the history include the following:
A. Are the symptoms acute, chronic, or recurrent?
B. If vomiting is the predominant feature, consider GI infection, reflux, gastritis, or ulcer.
C. Nausea as the predominant feature often results from systemic problems.
D. Is there a history of travel, drinking unsafe water, or eating unusual or uncooked food?
E. Is there a history of fevers or chills (Chapter 2.6.)?
F. Are general systemic symptoms or signs such as edema, discolored urine or jaundice, fatigue, weight loss or anorexia, headache, or blurred vision present?
G. Are psychiatric symptoms present?
H. Is the patient taking any medications?
I. Is diarrhea present?
J. Is there abdominal pain? The presence of abdominal pain raises some important and potentially serious possibilities:
1. Common problems presenting with abdominal pain and vomiting include cholecystitis, appendicitis, gastritis or ulcer, hepatitis, small bowel obstruction, inferior myocardial infarction or ischemia, renal colic, peritonitis, pancreatitis, food poisoning, and complications of pregnancy.
2. Uncommon problems presenting with abdominal pain and vomiting include diabetic ketoacidosis, drug withdrawal, uremia, and vasculitis or abdominal migraine.
3. Rare problems presenting with abdominal pain and vomiting include porphyria, lead intoxication, adrenal insufficiency, hyperlipidemia, abdominal epilepsy, glaucoma, hypercalcemia, and acute hemolysis.
Physical examination.
A directed physical examination is dictated by the findings on history, but the following are areas of key importance:
A. Vital signs. Focus on presence of fever, pulse, and blood pressure to assess hydration, and respiratory rate to look for acidosis-related hyperventilation.
B. Skin, eyes, mucous membranes. Look for dehydration and signs of jaundice.
C. Signs of systemic infection. Pay special attention to examining the lung and the costovertebral angle for tenderness.
D. A detailed abdominal examination should include inspection, auscultation, palpation, percussion, areas of tenderness, rebound, guarding, hepatomegaly, Murphy’s sign, stool for occult blood, and bimanual pelvic examination.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Nausea/Vomiting:
Differential Overview
(Field Guide to Bedside Diagnosis)
Presenting Symptom
❑ Gastroesophageal reflux
❑ Pregnancy
❑ Psychogenic
❑ Bulimia
❑ Rumination
❑ Diabetic ketoacidosis
❑ Hepatitis
❑ Inferior myocardial infarction
❑ Uremia
❑ Adrenal insufficiency
With Abdominal Pain
❑ Viral gastroenteritis
❑ Food poisoning
❑ Peptic ulcer disease
❑ Renal colic
❑ Pancreatitis
❑ Pyelonephritis
❑ Appendicitis
❑ Cholecystitis
❑ Small bowel obstruction
❑ Peritonitis
With Neurologic Signs
❑ Migraine headache
❑ Vestibular disturbance
❑ Autonomic dysfunction
❑ Increased intracranial pressure
❑ Hypercalcemia
❑ Cerebellar hemorrhage
Diagnostic Approach
Neurological vomiting may be projectile (forceful emesis without prior nausea), positional, or associated with other neurological signs. Central vomiting (chemoreceptor trigger zone stimulation, usually caused by toxins) is alleviated by antidopaminergic medications, which do not work well when treating nausea due to mechanical causes such as obstruction.
Early morning nausea suggests pregnancy or metabolic causes (e.g., uremia). Vomiting of a large amount of undigested food 4 to 6 hours after eating is consistent with gastric retention resulting from pyloric obstruction
or gastroparesis or to esophageal disorders such as achalasia or Zencker diverticulum. Feculent vomiting suggests intestinal obstruction or gastrocolic fistula.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Gastroenteritis:
Diagnosis
(Handbook of Diseases)
Patient history can aid diagnosis of gastroenteritis. A stool culture should be obtained. Blood cultures are indicated in febrile patients.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Bowel sounds, hyperactive:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Determine if there’s a history of hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Determine if there’s a history of IBD, eruptions of gastroenteritis among family members, friends, or coworkers. Ask if the patient has traveled recently, even within the United States.
In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids.Obtain a full medication history, including
over-the-counter medications.
ALERT: Homosexual males who report acute diarrhea and exhibit negative fecal ova and parasite cultures may be infected with chlamydial proctitis not associated with lymphogranuloma venereum. Because rectal cultures will probably be negative, treatment with tetracycline is appropriate.
Physical examination
Check for fever, which suggests infection. Complete a full GI assessment by inspecting abdominal contour. Stoop at the recumbent patient’s side and then at the foot of his bed to detect localized or generalized distention. Auscultate the abdomen and note bowel sounds. Percuss and palpate the abdomen gently. Palpate for abdominal rigidity and guarding, which suggest peritoneal irritation that can lead to paralytic ileus.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Vomiting:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Ask the patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.
Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.
Physical examination
Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.
During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure (ICP), a life-threatening emergency. If this occurs in a patient with a CNS injury, you should quickly check his vital signs. Stay alert for widened pulse pressure or bradycardia.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Abdominal distention:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing when lying flat or breathing deeply. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.
Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, and inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Bowel sounds, hyperactive:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If you’ve ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vomiting:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes, page 700.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.
Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Regurgitation and Vomiting:
Clinical Features and Diagnosis: Regurgitation
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Normal Variations
If the patient's abdominal distention isn't acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat.
The patient may be unable to bend at the waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.
Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) When did the patient last have a bowel movement? Note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones such as falling off a stepladder.
Perform a complete physical examination. Don't restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it's also common in obesity and pregnancy. Inspect the abdomen for signs of inguinal or femoral hernia and for healed incisions that may point to adhesions. Both may lead to intestinal obstruction. Auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.
Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally with the patient in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen without shifting dullness, prominent tympany, or palpable bowel or other masses, with generalized rather then localized dullness.
Palpate the abdomen for tenderness, noting whether it's localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney's point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient's abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.
If you've ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient's problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.
Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.
Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask the patient about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant or which contraceptive method she's using.
Inspect the patient's abdomen for distention and localized bulging, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness and test for rebound tenderness. Palpate and percuss the liver for enlargement. Assess the patient's other body systems as appropriate.
During the examination, keep in mind that projectile vomiting unaccompanied by nausea may be an indication of increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.
The association of other symptoms and signs is essential in pinpointing
the diagnosis of vomiting. For example, vomiting with tinnitus and vertigo
suggests Ménière disease, whereas vomiting with hematemesis suggests
gastritis, esophageal varices, and gastric ulcers. The laboratory workup
should include a flat plate of the abdomen, upper GI series, esophagram,
cholecystogram, gastric analysis, serum electrolytes, and amylase and lipase
levels. Stools for occult blood, ova, and parasites are usually indicated.
Gastroscopy and esophagoscopy are often indicated in the acute case, but an
exploratory laparotomy should not be delayed if the patient’s condition is
deteriorating and pancreatitis has been excluded.
Diagnosis of enteric fever rests on isolation of the organism from blood
culture. Blood cultures are positive in a large percentage of patients. Stool
cultures can also be positive and may be diagnostic in the correct clinical
setting. Febrile agglutinins (Widal
’s test) have previously been used, with elevation of O and H titers greater than
1:160 being diagnostic. Currently, these tests are not recommended owing to
high rates of false-positive and false-negative results.
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Diagnosing irritable bowel syndrome today is often simpler than it has been in the past. Doctors used to focus on ruling out other diseases and...
Some people with vague digestive symptoms needlessly suffer in silence believing there is no treatment. Abdominal discomfort, bloating, and either...
Pain and bowel irregularities caused by irritable bowel syndrome (IBS) can make a marked impact on day-to-day living. Abdominal discomfort, bloating,...