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40YO man with vomiting for past 2 days (Nature of vomited matter…
40YO man with vomiting for past 2 days
Details of symptoms
Onset
Abrupt
Cholecystitis. Other sx: RUQ pain, fever
Food poisoning. Other Sx: ask contact hx, fever, diarrhoea
Gastroenteritis. Other Sx: diarrhoea; dehydration, may have mild abdominal pain, usu. otherwise well patient
Illicit drugs
Medications, could be insidious onset
Pancreatitis. Refer to pain (well-localized). Other sx: dyspnea (diaphragmatic inflammation)
Insidious
GERD. Other sx: heartburn; regurgitation; dysphagia
Gastroparesis. Other sx: early satiety; postprandial bloating; abdominal discomfort
Metabolic disorders, e.g. hypothyroidism, adrenal insufficiency, diabetic gastroparesis. Other sx: ask about hot/cold.
Timing
Before breakfast
Ethyl alcohol
Increased intracranial pressure. Other sx: headache; papilloedema
Uremia. Other sx: peripheral neuropathy
During/directly after eating
Psychiatric causes
Less likely: PUD or pyloric stenosis. PUD other sx: epigastric pain worsens with eating; early satiety; fatty food intolerance (?)
1-4h post-meal => Gastric outlet obstructions e.g. PUD, neoplasms OR gastroparesis. Other Sx for gastroparesis: constipation; could have abdominal distension; weight loss secondary to sitophobia; abdominal pain
Continuous/irregular => Conversion disorder/depression
Nature of vomited matter
Undigested food => Achalasia (insidious onset), esophageal strictures e.g. diverticulum or strictures. Other sx: dysphagia
Partially digested food => Gastric outlet obstruction, gastroparesis
Malignant
Benign
Bile => small bowel obstruction (low obstruction below ampulla of Vater). Other Sx: severe pain (that precedes vomiting); abdominal distension
Feculent/odorous => fistula, (low) bowel obstruction with bacterial degradation of contents
Large volume >1500ml in 24h => organic, not psychiatric cause. Haemetemesis => major upper GI bleed from peptic ulcer, varices
Abdominal Pain?
Right upper quadrant => Biliary tract disease, cholecystitis (refer to onset)
Epigastric => Pancreatic disease, PUD. Radiate to back => Pancreatitis
Severe pain => Biliary disease, pancreatic disease, peritoneal irritation
RLQ => acute appendicitis
Ask to describe associated symptoms, i.e. pain, onset of sx, weight loss, fever
Contact hx with ill persons => viral. Other sx: diarrhoea, myalgias, malaise, headache. Could be food poisoning.
Headache => encephalitis/meningitis. Other sx: stiff neck; focal neurologic deficits; altered mental status OR migraine. Other sx: repetitive migraine headaches or irritable bowel syndrome sx => cyclic vomiting syndrome (recurrent but intermittent pattern)