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40-year old man with vomiting for 2 days (PHYSICAL EXAMINATION (Signs of…
40-year old man with vomiting for 2 days
Infections
Acute otitis media, bacteria, bacterial toxins, food-borne toxins, pneumonia, spontaneous bacterial peritonitis, UTI/pyelonephritis, viruses (adenovirus, norwalk, rotavirus)
Typically acute onset of symptoms, self-limiting
Gastrointestinal disorders
Functional disorders
: chronic intestinal pseudo-obstruction, gastroparesis, irritable bowel syndrome, non-ulcer dyspepsia
Obstruction
: adhesions, esophageal disorders/achalasia, intussusception, malignancy, pyloric stenosis, stragulated hernia, volvulus
Organic disorders
: appendicitis, cholecystitis/cholangitis, hepatitis, IBD, mesenteric ischemia, pancreatitis, peptic ulcer disease, peritonitis
Gastric outlet obstruction tend to cause intermittent symptoms vs. intestinal obstructions typically cause acute symptoms and severe pain; motility disorders typically produce insidious onset of symptoms
CNS and psychiatric
Closed head injury, migraine, seizure disorder
Increased intracranial pressure
: cerebrovascular accident e.g. infarc/hemorrhage, hydrocephalus, mass lesion, meningitis/encephalitis/abscess, pseudomotor cerebri
Vestibular
: labyrinthitis, Meniere's disease, motion sickness
Usually present with additional neurological signs e.g. cranial nerve dysfunction or long-tract signs; conditions affecting labyrinthus e.g. infections, Meniere's disease and tumors, are often associated with vertigo; migraine headaches classically cause nausea/vomiting
PHYSICAL EXAMINATION
Signs of dehydration (skin turgor and mucous membranes, hypotension or orthostatic changes)
Jaundice, lymphadenopathy, signs of thyrotoxicosis
Observe fingers for calluses on dorsal surfaces suggesting self-induced vomiting
Parotid gland enlargement, lanugo hair, loss of tooth enamel
Signs of depression or anxiety, suggesting psych etiologies
Abdominal distention with tenderness suggestive of bowel obstruction; bloating may occur with gastroparesis
Visible peristalsis, abdominal or inguinal hernias and surgical scars
Auscultation: increased bowel sounds in obstruction or decreased bowel sounds with ileus
Succussion splash heard at epigastrium while rapidly palpating epigastrium or shaking abdomen and pelvis suggests gastric outlet obstruction or gastroparesis
Epigastric tenderness may suggest ulcer or pancreatitis
Pain in upper right quadrant suggests cholecystitis or biliary tract disease
Decrease in BP without change in heart rate may suggest autonomic neuropathy with coexisting motility disorders
Deficit in cranial nerves of patient's gait suggests brainstem lesions which may lead to gastroparesis
Ophthalmoscopy to be performed to evaluate for increased intracranial pressure
Nystagmus may suggest disorder of labyrinthine system
HISTORY
Clear definition of patient's symptoms; distinguish vomiting from regurgitation and rumination
Onset
: abrupt (cholecystitis, food poisoning, gastroenteritis, illicit drugs, medications, pancreatitis) vs. insidious (GERD, gastroparesis, medications, metabolic disorders, pregnancy)
Timing
: before breakfast (ethyl alcohol, increased intracranial pressure, pregnancy, uremia) vs. during or directly after eating (psychiatric causes, less likely peptic ulcer disease or pyloric stenosis) vs. 1-4 hrs after meals (gastric outlet obstruction e.g. from PUD or neoplasms, gastroparesis) vs. continuous (conversion disorder, depression) vs. irregular (major depression)
Nature of vomited matter
: undisgested food (achalasia, esophageal disorder e.g diverticulum, strictures) vs. partially digested food (gastric outlet obstruction, gastroparesis) vs. bile (proximal small bowel obstruction) vs. feculent or odorous (fistula, obstruction with bacterial degradation of contents) vs. large volume of >1,500 ml per 24 hours suggests organic rather than psychiatry causes)
Associated symptoms/findings
: weight loss (malignancy) vs. diarrhea/myalgias/malaise/headache/contact with ill persons/headache/stiff neck/vertigo/focal neurological deficits vs. headache, contact with ill persons (viral etiologies) vs. headache/stiff neck/vertigo/focal neurological deficits (central neurologic causes e.g. meningitis/encephalitis, head injury, increased intracranial pressure, migraine) vs. early satiety, postprandial bloating, abdominal discomfort (gastroparesis) vs. repetitive migraine headaches or symptoms of IBS (cyclic vomiting syndrome)
Location of abdominal pain
: right upper quadrant (biliary tract disease, cholecystitis) vs. epigastric (pancreatic disease, PUD) vs. severe pain (biliary disease, pancreatic disease, peritoneal irritation, small bowel obstruction) vs. severe pain that precedes vomiting (small bowel obstruction)
Metabolic
Adrenal disorders, diabetic ketoacidosis, paraneoplastic syndromes, parathyroid disorders, pregnancy, thyroid disorders, uremia
Misc
Acute glaucoma, acute MI, nephrolithiasis, pain, psychiatric disorders (anorexia nervosa, anxiety, bulimia nervosa, conversion disorder, depression), psychogenic/ emotional
Pregnancy (not in this patient!)
Medications/ toxins
Antiarrhythmics, antibiotics, anticonvulsants, chemotherapeutics, digoxin, ethanol overdose, hormonal preparations, illicit substances, NSAIDs, opiates, overdoses/withdrawal, radiation therapy
Toxins: arsenic, organophosphates/pesticides, ricin
Typically cause nausea and vomiting early in their course, although onset may be insidious