Vomiting Flashcards
Mr CL, 53 year old male, presents to ED with 3/7 of vomiting
What do you need to know about the vomiting?
Onset Amount Colour (bilious, faeculant) ?blood Associated features: fever, nausea, lethargy, anorexia and LOW, dizziness/falls and LOC, tachycardia FHx of bowel disease
What are the causes of vomiting?
Infectious Metabolic: endocrine emergencies, electrolyte disturbance Surgical: acute abdomen, obstruction Neurological: raised ICP, migraine Pregnancy Drugs and alcohol Severe pain Meniere's disease (excess of fluid in inner ear)
Mr CL describes his vomitus as thick and brown
It smells like faecal matter and tastes foul
He fills half an ice cream container with vomit every couple of hours
Began 3/7 ago and was more green at first; there is no blood
Associated features: 2/52 progressively worsening abdominal distension, 1/52 mild abdominal cramping
Last BM 2/52 ago, last passed gas 3/7 ago (usually moves bowels every 2/7 regularly)
Nil blood in motions
What is the relevance of the nature of the vomitus as described?
Faeculant vomiting suggests that the level of obstruction is beyond the small bowel (distal obstruction)
Mr CL continued: no previous colonoscopy, recent marked anorexia and LOW but no fevers/chills
PHx: recent ex-alcohol abuse, COPD, gastric ulcer, no surgeries
Rx: warfarin (indication was DVT)
SHx: lives alone, unemployed, recent major social stressors, ex-smoker, supportive sister, functionally reasonably well
FHx: nil of note
What are you looking for O/E?
General inspection: pain, movement
Hands: temperature and claminess, tissue turgor, capillary refill, signs of anaemia, signs of chronic alcoholism, nicotine stains, metabolic flap
Pulse, BP (lying and standing), RR
Face: conjunctival pallor, scleral icterus, mucous membranes, central cyanosis
Neck: JVP, LNs, carotid auscultation for bruits
Chest: spider naevi, gynaecomastia, palpation of apex beat, auscultation of heart and lungs
Abdominal: caput medusae, scars, distension, asymmetry, masses or lumps, skin changes, hernias, percussion (including for shifting dullness), palpation, auscultation (for succussion splash, tinkling bowel sounds, absent bowel sounds)
Groin: hernia, pulses, listen for bruits, LNs, scrotal exam
Legs: pedal pulses, peripheral oedema, inspect for pressure ulcers
DRE
What diagnosis is absence of bowel sounds consistent with?
More consistent with ileus than obstruction
What is ileus? When does it typically occur? How do you distinguish between an ileus and other causes of bowel obstruction?
Complete lack of peristalsis of the bowel
Can occur post-op
Pain from ileus is a “fullness”, and not the characteristic colicky pain seen in other causes of bowel obstruction
Mr CL looks fatigued and much older than his 53 years
His arms and legs are wasted and he has a very distended abdomen
He is lying comfortably without signs of distress
No signs of anaemia, pallor, jaundice
No lymphadenopathy
No peripheral stigmata of note
JVP 0cm, BP 120/90, HR 80 regular, HS dual+0
RR 20, SaO2 90% on RA, BS vesicular nil added
Abdomen grossly distended, symmetrical, no scars, tympanic on percussion with increased bowel sounds, essentially non-tender with no signs of peritonitis, non-palpable liver
Empty rectum on DRE
What are the causes of abdominal distension and how can you distinguish between these?
Faeces
Flatus
Foetus: ask about LMP, listen for foetal HS, perform a B-hCG
Fat
Fluid: shifting dullness
Frightfully large tumour: might be visible or palpable
How can you tell the difference on palpation between a lump superficial to the peritoneum vs deep?
Ask the patient to tense their abdominal muscles by lifting their head and shoulders off the bed: if the mass is still there, it is superficial
List some DDx for a superficial abdominal mass
Skin: abscess, sebaceous cyst, tumour
Fat: lipoma
Muscle: haematoma, tumour
Hernia
How can you infer the origin of a deep abdominal mass on physical examination?
Location correlates to organs (manipulation may assist in localising, e.g. balloting for kidneys)
Ix for bowel obstruction?
CXR Erect and supine AXR FBE: WCC, Hb UEC: electrolyte disturbance, urea/creatinine CRP Coagulation profile
