You are seeing Frank, a 27 year old homeless male, who was brought into the ER by police because he was found vomiting in a nearby alleyway. Take a history of his complaint. Then, perform a focused physical examination.
History
- Onset of vomiting
- Contents/ appearance of vomitus
- Blood in vomit
- Recent alcohol intake
- Change in bowel habit
- Association with abdominal pain
- Severity of abdominal pain
- Radiation of abdominal pain
- Association of abdominal pain with position (worse when supine)
- Fever
- Relevant social history, including current housing state
- Alcohol history
- Assessment for alcohol abuse (CAGE)
- Drug history
- Hepatitis status, past vaccination
Physical examination
Inspection/Auscultation
- Comments on patient’s overall appearance, including jaundice and muscle wasting
- Notes any stigmata of chronic liver disease
- Inspects for masses and bulging flanks
- Inspects for Cullen’s and Grey Turner’s signs
- Auscultates in all four quadrants of the abdomen
Percussion/Palpation
- Uses light and deep palpation to examine for tenderness
- Monitors patient’s reaction to palpation in epigastrum, commenting on guarding
- Assesses for peritoneal findings, including rebound and shake tenderness
- Estimates liver span using percussion
- Palpates for splenomegaly
- States that they would perform digital rectal examination as part of the abdominal examination
Special Maneuvers
- Assesses if pain varies with position (comments that pain associated with pancreatitis is somewhat alleviated when patient leans forward)
- Assesses for asterixis and ascites
Case 3 – Vomiting