Nausea and Vomiting (Case 20)

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Nausea and Vomiting (Case 20)

Owen Tully MD and Bob Etemad MD

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.

Differential Diagnosis

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Speaking Intelligently

PATIENT CARE

Clinical Thinking

• 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.

History

• 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.

Physical Examination

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

Complete blood count (CBC): Leukocytosis is very nonspecific.
A normal CBC is somewhat reassuring but never an “all clear” in these patients. New significant anemia could be an actual cause of symptoms or suggest intra-abdominal/retroperitoneal bleeding.

$11

Comprehensive metabolic panel (CMP): Look for acidosis and increased blood urea nitrogen-to-creatinine (BUN/Cr) ratio as suggestive of volume depletion. An anion gap acidosis could suggest ischemia or iatrogenic etiologies.

$12

Human chorionic gonadotropin (HCG): If premenopausal female, to exclude pregnancy and related issues

$9

Urinalysis: Look for pyuria and bacteriuria; urine is concentrated in patients with infection or volume depletion.

$4

Amylase/Lipase: For consideration of pancreatitis

$19

Esophagogastroduodenoscopy (EGD): Evaluate for gastritis, esophagitis, peptic ulcer disease (PUD).

$600

Electrocardiography (ECG): Assess for acute ischemia as a contributing cause of symptoms or secondary effect.

$27

 

IMAGING CONSIDERATIONS

→ Obstruction series: At least two views and erect/lateral view to evaluate for pneumoperitoneum. A large gastric air bubble or gastric outline suggests gastroparesis/gastric outlet obstruction. Small-bowel air-fluid levels suggest ileus. Distended loops of bowel suggest obstruction. Large amount of stool suggests constipation/obstipation.

$75

→ CT scan or ultrasound should be considered if the patient has abdominal tenderness or features suggestive of acute cholecystitis or appendicitis.

$334, $96

→ Other:

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