gastrointestinal disorders
Nausea and Vomiting
Evaluation of Nausea and Vomiting
History of present illnessshould elicit frequency and duration of vomiting; its relation to possible precipitants such as drug or toxin ingestion, head injury, and motion (eg, car, plane, boat, amusement rides); and whether vomitus contained bile (bitter, yellow-green) or blood (red or “coffee ground” material). Important associated symptoms include presence of abdominal pain and diarrhea, the last passage of stool and flatus, and presence of headache, vertigo, or both. Review of systemsseeks symptoms of causative disorders such as amenorrhea and breast swelling (pregnancy), polyuria and polydipsia (diabetes), and hematuria and flank pain (kidney stones). Past medical historyshould ascertain known causes such as pregnancy, diabetes, migraine, hepatic or renal disease, cancer (including timing of any chemotherapy or radiation therapy), and previous abdominal surgery (which may cause bowel obstruction due to adhesions). All drugs and substances ingested recently should be ascertained; certain substances may not manifest toxicity until several days after ingestion (eg,acetaminophen, some mushrooms). Family history of recurrent vomiting should be noted. Vital signs should particularly note presence of fever and signs of hypovolemia (eg, tachycardia, hypotension, or both). General examination should seek presence of jaundice and rash. On abdominal examination, the clinician should look for distention and surgical scars; listen for presence and quality of bowel sounds (eg, normal, high-pitched); percuss for tympany; and palpate for tenderness, peritoneal findings (eg, guarding, rigidity, rebound), and any masses, organomegaly, or hernias. Rectal examination and (in women) pelvic examination to locate tenderness, masses, and blood are essential. Neurologic examination should particularly note mental status, nystagmus, meningismus (eg, stiff neck, Kernig sign or Brudzinski sign), and ocular signs of increased intracranial pressure (eg, papilledema, absence of venous pulsations, 3rd cranial nerve palsy) or subarachnoid hemorrhage (retinal hemorrhage). The following findings are of particular concern: Signs of hypovolemia Headache, stiff neck, or mental status change Peritoneal signs Distended, tympanitic abdomen Many findings are suggestive of a cause or group of causes (see table). Vomiting occurring shortly after drug or toxin ingestion or exposure to motion in a patient with an unremarkable neurologic and abdominal examination can confidently be ascribed to those causes, as may vomiting in a woman with a known pregnancy and a benign examination. Acute vomiting accompanied by diarrhea in an otherwise healthy patient with a benign examination is highly likely to be infectious Overview of Gastroenteritis ; further assessment may be deferred. Vomiting that occurs at the thought of food or that is not temporally related to eating suggests a psychogenic cause, as does personal or family history of functional nausea and vomiting. Patients should be questioned about the relationship between vomiting and stressful events because they may not recognize the association or even admit to feeling distress at those times. All females of childbearing age should have a urine pregnancy test. Patients with severe vomiting, vomiting lasting over 1 day, or signs of dehydration on examination should have other laboratory tests (eg, electrolytes, bloodureanitrogen, creatinine, glucose, urinalysis, sometimes liver tests). Patients with red flag findings should have testing appropriate to the symptoms (see table). The assessment of chronic vomiting usually includes the previously listed laboratory tests plus upper GI endoscopy, small-bowel x-rays, and tests to assess gastric emptying and antral-duodenal motility. 