Physical Exam Key Points

1. Vital signs and general appearance. Used to assess patient's hemodynamic condition. A child may lose up to 15% of body fluid volume without significant hemodynamic change. Tachycardia is the first cardiovascular change seen.

2. Head and neck. Visualize posterior nose and pharynx to exclude epistaxis. Examine for scleral icterus for possible liver disease. Periorbital petechiae suggest vigorous vomiting associated with Mallory-Weiss tear.

3. Abdomen. Presence of distention, absence of bowel sounds, or peritoneal findings are associated with ischemic or obstructive lesions. Hepatosplenomegaly and ascites suggest chronic liver disease or failure. Epigastric tenderness may be elicited with gastroesophageal ulcerations.

4. Skin. Prominent abdominal venous pattern or spider nevi suggest liver disease; cutaneous hemangiomas may suggest an underlying vascular malformation.

B. Laboratory Data

1. Fecal occult blood test (Gastroccult). Will determine whether substance is actually blood.

2. Apt-Downey test. Differentiates fetal hemoglobin from maternal hemoglobin, identifying whether blood comes from infant or mother.

3. Type and cross-match. Indicated with significant hemorrhage.

4. CBC. Hematocrit is an unreliable indicator in acute blood loss, declining only after extravascular fluid enters the intravascular space. Low WBC and platelet counts may be seen in hyper-splenism from portal hypertension and cancer. Microcytic anemia suggests chronic mucosal bleeding.

5. Liver function panel. Evaluates liver function and ability to produce coagulation factors.

6. PT and PTT. Used to evaluate coagulation cascade and liver function.

7. Basic metabolic panel. A BUN:creatinine ratio > 30 suggests blood resorption from the GI tract. Electrolyte abnormalities may be seen with hemolysis.

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