# Abdominal pain and vomiting as a fever settles in a 29-year-old: a live ward case

> A live ward case for medical students: abdominal pain, vomiting and weakness as a four-day fever comes down. What to ask, warning signs, fluid assessment, first tests and the differential.

- Infectious Disease · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/29-year-old-man-with-belly-pain-as-his-fever-settles
- Work up this patient: https://www.medikarya.in/case-studies/29-year-old-man-with-belly-pain-as-his-fever-settles

## How the patient presents

He has had a high fever for four days. It came down yesterday, but today he has abdominal pain, keeps vomiting and feels too weak to stand. His friend brought him in.

## 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.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.