22 | Abdominal Key

History

A 88-year-old gentleman from a nursing home is brought to the accident and emergency department after ingestion of a foreign body. The caregiver suspects he had swallowed a five dollar coin (Figure 22.1). He subsequently develops chest pain and epigastric discomfort hours after ingestion. He has a past history of hypertension, diabetes mellitus and dementia.

Physical examination

•Afebrile, pulse 94 bpm, BP 160/80mmHg, SaO₂ 98% on RA.

•Hydration is satisfactory.

•Examination of the hands reveals no clubbing and normal-appearing palmar creases.

•Head and neck examination is unremarkable.

•Cardiovascular: HS dual, no murmur.

•His chest is clear on auscultation, with no stridor. He is not in respiratory distress.

•Abdominal examination reveals a soft abdomen, with no tenderness/guarding/rebound tenderness. Bowel sounds are normal.

•No signs of oedema.

Investigations

•CBC:

–WBC 7.9 x 10⁹/L;

–haemoglobin 13g/dL;

–platelets 226 x 10⁹/L.

•Liver function tests are normal.

•CRP normal.

•Clotting profile is normal.

What other physical examinations would you like to perform?

A complete neck exam looking for erythema, tenderness, swelling or crepitus should be performed. If crepitus is present it would be suggestive of subcutaneous emphysema and raises the suspicion of a perforated viscus.

What further investigations would you request?

Radiographs would be useful for localisation and screening for complications, such as free gas under the diaphragm or mediastinal gas.

A lateral radiograph of the neck together with a chest X-ray are performed (Figure 22.2).