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:
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)?
• 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.
• 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.
• 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.
• 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?
• 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.
• 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.