Nausea and Vomiting (Case 20)
Case: A 65-year-old woman presents with nausea and vomiting. She has a past medical history of hypertension, hyperlipidemia, type 2 diabetes mellitus, mild obesity, and a recent diagnosis of a herniated lumbar disk; her surgical history includes a hysterectomy for fibroid disease. She states the nausea and vomiting has been worsening for 3 days, usually after meals, and is associated with crampy abdominal pain before these episodes. She was recently seen by her primary physician, who added glipizide to her medical regimen because her hemoglobin A1c (HgbA1c) was not well controlled. She has also recently been started on a fentanyl patch for worsening pain in her cervical spine secondary to her herniated disk.
When a patient presents with symptoms of nausea and vomiting, it is important to consider that some patients may vomit and have minimal nausea, whereas others present with long durations of nausea punctuated with a rare episode of vomiting that does not relieve the nausea. Among the more important factors to consider are the following:
Are the symptoms acute or chronic? Acute nausea or vomiting usually suggests a more urgent issue.
Does the patient have a chronic medical condition in which nausea or vomiting may be a manifestation of a life-threatening complication of that condition (cardiovascular disease, diabetes, neurologic disorder, active malignancy)?
What is the relationship between the patient’s nausea and his or her vomiting? Timing, duration, exacerbating factors, associated symptoms, and new medications must be considered.
Is there any possibility of pregnancy?
Are there other signs or symptoms that the patient is significantly ill?
• Initially rule out potentially catastrophic causes for the symptoms; consider intestinal infarction, perforated viscus, volvulus, cerebral edema, hypoglycemia, and cardiac disease.
• In any woman of childbearing age, be sure to exclude pregnancy.
• Determine the time frame of symptoms. If the symptoms are roughly 1 month or less, an acute cause of the symptoms should be considered, as catastrophic and more dangerous etiologies tend to manifest acutely.
• Asking about associated abdominal pain is often helpful in determining the etiology, especially for acute intraperitoneal conditions such as pancreatitis and appendicitis. Be aware that post-emetic abdominal pain may be related to worsening acid reflux secondary to the vomiting itself.
• Consider extraintestinal conditions causing nausea and vomiting, including electrolyte and glucose imbalance, neurologic disorders, renal colic, biliary colic, and ovarian or testicular torsion.
• While pursuing the underlying etiology, monitor and correct potential complications of nausea and vomiting, including metabolic and electrolyte abnormalities, and volume depletion.
• Clarify whether nausea or vomiting is the predominant symptom, and detail each symptom separately: onset, frequency, duration, associated symptoms, and medication use.
• Clarify the relationship between nausea and vomiting (which came first, which is predominant, and does vomiting relieve nausea).
• In considering infectious causes, ask whether close contacts have similar symptoms; ask about obvious new food exposure, diarrhea, change in bowel habits, and fever.
• Review medication history: New medications, missed medications, medications recently discontinued, wrong medications taken, or incorrect dose.
• In patients with diabetes, review recent glucose and HgbA1c levels, and any changes in diet, medications, and activity.
• In considering mechanical causes, ask about change in bowel habits, abdominal distension, more vomiting than nausea, abdominal pain, previous episodes, and previous history of mechanical bowel obstruction. Establish if any previous surgeries were performed, and consider reviewing the operative notes for any unusual circumstances surrounding the surgery.
• In considering neurologic causes, ask about vertigo, changes in vision, unilateral weakness, and headaches.
• Perform a detailed review of systems to consider the multitude of other etiologies.
• Vital signs: Patients with more severe symptoms may have orthostatic hypotension, tachycardia, or fever. Fever is common in patients with gastroenteritis, especially of bacterial etiology, but can also be seen with inflammatory conditions and drug reactions.
• Abnormal vital signs suggest a more concerning process needing more urgent attention.
• General appearance: Is the patient “miserable” or comfortable? Is there something obvious that strikes you as concerning (distended abdomen, lying in fetal position, abnormally quiet, not moving a particular extremity)? Does the patient appear ill?
• Check for signs of volume depletion by examining the oral mucous membranes, eyes, and skin.
• Lymphadenopathy could suggest either infectious causes or malignancy.
• Abdominal tenderness to palpation is a clue to potential inflammatory conditions of the abdomen, such as appendicitis, cholecystitis, colitis, and diverticulitis. Rebound and guarding are important clues regarding complications (e.g., perforation). A distended, tympanitic abdomen suggests ileus or bowel obstruction. Rectal exam may demonstrate an empty rectal vault. There may be an absence of bowel sounds.
• Signs of muscle atrophy, cachexia, and temporal wasting could suggest malignancy.
• Peripheral neuropathy can be seen in patients with or without diabetic gastroparesis.
• New neurologic abnormalities on physical exam (e.g., unilateral weakness, paresis, numbness, facial droop, or ptosis) could suggest central nervous system (CNS) processes causing nausea and vomiting.
Tests for Consideration