Foods Analysis: Methods have been developed for many foods having prior history of Salmonella contamination. Although conventional culture methods require 5 days for presumptive results, several rapid methods are available which require only 2 days.
(Source: FDA Bad Bug Book)
Diagnosis of Human Illness:
Serological identification of culture isolated from stool.
(Source: FDA Bad Bug Book)
Many different kinds of illnesses can cause diarrhea, fever, or
abdominal cramps. Determining that Salmonella is the cause of
the illness depends on laboratory tests that identify Salmonella
in the stools of an infected person. These tests are sometimes
not performed unless the laboratory is instructed specifically
to look for the organism. Once Salmonella has been identified,
further testing can determine its specific type, and which antibiotics
could be used to treat it. (Source: excerpt from Salmonellosis (General): DBMD)
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
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
Salmonellosis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Generally, diagnosis depends on isolation of the organism in a culture, particularly blood (in typhoid, paratyphoid, and bacteremia) or feces (in enterocolitis, paratyphoid, and typhoid). Other appropriate culture specimens include urine, bone marrow, pus, and vomitus. In endemic areas, clinical symptoms of enterocolitis allow a working diagnosis before the cultures are positive. The presence of Salmonella typhi in stool 1 or more years after treatment indicates that the patient is a carrier, which is true of 3% of patients.
Widal’s test, an agglutination reaction against somatic and flagellar antigens, may suggest typhoid with a fourfold rise in titer. However, drug use or hepatic disease can also increase these titers and invalidate test results. Other supportive laboratory values may include transient leukocytosis during the 1st week of typhoidal salmonellosis, leukopenia during the 3rd week, and leukocytosis in local infection.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Poisonous snakebites:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
The patient’s history and account of the injury, observation of fang marks, snake identification (when possible), and progressive symptoms of envenomation all point to poisonous snakebite. Laboratory test results help identify the extent of envenomation and provide guidelines for supportive treatment.
Abnormal test results in poisonous snakebites may include:
❑ prolonged bleeding time and partial thromboplastin time
❑ decreased hemoglobin level and hematocrit
❑ sharply decreased platelet count (less than 200,000/mm">3)
❑ urinalysis disclosing hematuria
❑ increased white blood cell count in victims who develop an infection (a snake’s mouth typically contains gram-negative bacteria)
❑ pulmonary edema or emboli as shown on chest X-ray
❑ possibly tachycardia and ectopic heartbeats on the electrocardiogram (usually necessary only in cases of severe envenomation for a patient older than age 40)
❑ possibly abnormal EEG findings in cases of severe envenomation.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
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
Salmonellosis:
Diagnosis
(Handbook of Diseases)
Generally, diagnosis depends on isolation of the organism in a culture, particularly blood (in typhoid, paratyphoid, and bacteremia) or feces (in enterocolitis, paratyphoid, and typhoid). Other appropriate culture specimens include urine, bone marrow, pus, and vomitus.
In endemic areas, signs and symptoms of enterocolitis allow a working diagnosis before cultures are positive. Presence of S. typhi in stools 1 or more years after treatment indicates that the patient is a carrier, which is true of 3% of patients.
Widal’s test, an agglutination reaction against somatic and flagellar antigens, may suggest typhoid with a fourfold rise in titer. However, drug use or hepatic disease can also increase these titers and invalidate test results.
Other supportive laboratory values may include transient leukocytosis during the 1st week of typhoidal salmonellosis, leukopenia during the 3rd week, and leukocytosis in local infection.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Snakebites, poisonous:
Diagnosis
(Handbook of Diseases)
The patient’s history and account of the injury, observation of fang marks, snake identification (when possible), and progressive symptoms of envenomation all point to poisonous snakebite. Laboratory test results help identify the extent of envenomation and provide guidelines for supportive treatment.
Abnormal test results in poisonous snakebites may include the following:
❑ prolonged bleeding time and partial thromboplastin time
❑ decreased hemoglobin and hematocrit values
❑ sharply decreased platelet count (less than 200,000/µl)
❑ urinalysis disclosing hematuria
❑ increased white blood cell count in victims who develop an infection (the mouth of a snake typically contains gram-negative bacteria)
❑ pulmonary edema as shown on chest X-ray
❑ possibly tachycardia and ectopic heartbeats on the electrocardiogram (usually necessary only in cases of severe envenomation for a patient older than age 40)
❑ possibly abnormal EEG findings in cases of severe envenomation.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
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
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
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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