Why abdominal pain and vomiting after a fever matters
Abdominal pain and vomiting after several days of fever can be a new surgical problem, a complication of the infection itself, or a patient becoming dry or going into shock. Which one it is changes everything, so his circulation and the trend of his observations matter as much as his abdomen.
What to ask in the history
- Fever: how many days, how high, when it came down
- The pain: where, constant or coming in waves, what makes it worse
- Vomiting: how often, and can he keep fluids down
- How much urine he has passed today
- Bleeding anywhere: gums, nose, vomit, stools, skin spots
- Where he lives and works, local outbreaks, mosquitoes, flood water, animals
- Jaundice, alcohol
- Every medicine taken for the fever, including injections and painkillers
Red flags
- Persistent vomiting, unable to drink
- Severe or worsening abdominal pain
- Bleeding from any site
- Restless, drowsy or confused
- Cold hands, fast pulse, low or narrowing blood pressure
- Little or no urine
- An enlarging liver, or fluid in the abdomen or chest
What to examine
- Pulse, blood pressure (and the gap between the two readings), capillary refill, temperature of the hands and feet
- Hydration
- Skin: rash, small bleeding spots, jaundice
- Abdomen: tenderness, guarding, liver and spleen, fluid
- Chest: signs of fluid at the bases
- A record of urine output
First investigations
- Full blood count with haematocrit and platelets, repeated to see the trend
- Liver function, kidney function, electrolytes
- Malaria test
- Tests for the fevers common locally, chosen by the history
- Blood culture
- Ultrasound of the abdomen
- Amylase or lipase if the pain suggests it
Differential diagnosis of abdominal pain and vomiting after a fever
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Surgical
- Appendicitis
- Cholecystitis
- Pancreatitis
- Perforation
Other infections
- Typhoid, including perforation
- Leptospirosis
- Scrub typhus
- Malaria
- An abdominal source of sepsis
Viral fevers
- Dengue
- Other mosquito-borne viral fevers
- Viral hepatitis
Other
- Dehydration and electrolyte upset
- Gastritis from painkillers
Common mistakes
- Taking a falling temperature as a sign he is getting better.
- Judging from one blood count instead of the trend.
- Giving fluids by formula without reassessing him after each step.
- Giving anti-inflammatory painkillers or intramuscular injections before the platelet count is known.